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Inspection carried out on 17 July 2018

During a routine inspection

This unannounced comprehensive inspection took place on 17 and 26 July 2018.

Hill House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Hill House accommodates 30 people in one adapted building. At the time of our inspection there were 30 people living at the service.

Following the last inspection in August 2017, we asked the provider to complete an action plan to show what they would do and by when to improve the key question(s) Safe, Effective, Responsive and Well-led to at least good. At the previous inspection, we found the provider had failed to ensure staff received appropriate support, training and supervision. The provider also did not operate effective systems to ensure improvements were made to the quality and safety of the service. Records were not always accurate, complete and contemporaneous in respect of each service user. This inspection found improvements had been made. Staff were now receiving up to date training and support and systems to monitor the quality and safety of the service were more robust.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Staffing levels met people’s personal care needs. However, meaningful interactions were limited. The service was actively trying to recruit more staff to increase staffing levels. The service provided safe care to people. One person commented: “It's the staff, they make me feel safe”. Measures to manage risk were as least restrictive as possible to protect people’s freedom. People’s rights were protected because the service followed the appropriate legal processes. Medicines were safely managed on people’s behalf.

Care files were personalised to reflect people’s personal preferences. Their views and suggestions were taken into account to improve the service. People were supported to maintain a balanced diet. Health and social care professionals were regularly involved in people’s care to ensure they received the care and treatment which was right for them.

Staff relationships with people were caring and supportive. Staff were motivated to offer care that was kind and compassionate.

There were effective staff recruitment and selection processes in place. People received effective care and support from staff who were well trained and competent.

Staff spoke positively about communication and how the registered manager worked well with them.

A number of more robust methods were used to assess the quality and safety of the service people received. The service made continuous improvements in response to their findings.

Further information is in the detailed findings below.

Inspection carried out on 27 April 2017

During a routine inspection

Hill House is a residential care home that provides accommodation with personal care for a maximum of 29 older people. At the time of the inspection there were 29 living at the service.

This inspection took place on 27 and 28 April 2017. The first day of the inspection was unannounced. The service was last inspected on 28 May and 3 June 2015 when it was rated as good overall with responsive rated as requires improvement due to inconsistencies in record keeping. We issued a requirement. The provider had developed an action plan to ensure improvements were made. We found improvements had been made to some records but not consistently.

Prior to the inspection we received concerns from a visiting professional about staffing levels and concerns that people’s personal care was delayed and that they were isolated in their rooms due to staffing levels. There were concerns that some people did not appear to have access to their call bells when in their room. There were concerns about people who may be at risk of falls and some undocumented bruising found on two people. Medicines were not always stored securely in people’s rooms. We looked at all aspects of these concerns during the inspection. We also received an anonymous concern about the attitude of one staff member. This was thoroughly investigated by the provider and was not substantiated.

There was a manager at the service who was registered with CQC. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Staffing levels at the service were meeting people’s care needs; however due to high levels of sickness and the use of agency staff people expressed frustration that often staff did not know them well or understand their needs. Some people felt this and the approach of some staff impacted on their feeling of safety.

Some aspects of medicines management needed to improve to ensure practice was safe.

Staff had the knowledge they needed and understood people’s needs in order to carry out their roles; however several aspects of staff training had lapsed and some training was out of date, with staff requiring refresher training. Staff received annual appraisals however supervision of staff had lapsed.

Systems in place to monitor and improve the quality and safety of the service were not fully effective and timely action was not taken in response to known issues.

The majority of people said they felt safe. They were protected against the risk of abuse as the registered manager and staff understood their responsibilities to report any concerns. Plans were in place to keep people safe in emergency situations.

Risks to people using the service were assessed and plans put in place to reduce the chances of them occurring. Regular checks were made of the premises and equipment to ensure they were safe for people to use. Procedures were in place to monitor and respond to accidents and incidents. Staff were recruited using robust procedures intended to protect people from unsuitable workers.

People’s rights were protected because the registered manager acted in accordance with the Mental Capacity Act 2005.

People’s nutritional needs were met. Mealtimes were sociable and the registered manager was working to ensure people’s preferences with regards to food were also being met. People had access to a variety of health professionals for specialist advice and support when appropriate. The service had developed good working relationships with health and social professionals.

Overall people felt staff were kind and caring. Two people felt the approach of some staff was not as caring as others. Where people had raised concerns with the registered manager, these had been addressed and improvements we

Inspection carried out on 28 May and 3 June 2015

During a routine inspection

The inspection took place on 28 May and 3 June 2015 and was unannounced. We last inspected this service on 20 August 2014 and identified concerns in relation to consent and to people’s care and welfare. At this visit, improvements had been made to meet the relevant regulations.

The service is a residential care home that provides accommodation with personal care for a maximum of 29 older people. It has a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People’s care needs were assessed and care records had individualised information about each person’s needs. However, there were inconsistencies in quality of some care plans and in other day to day record keeping. This meant some people could be at increased risk because care records needed more up to date details and because of recording omissions.

People were treated with dignity and respect and staff were caring and compassionate towards them. People were supported to express their views and be involved in decision making about their care. They received care that was individual to their needs. Staff knew people well, about their needs and preferences and how they liked to spend their day. People were supported to remain active and independent and to pursue a variety of hobbies and interests and access the community on a regular basis.

A robust recruitment process was in place to make sure people were cared for by suitable staff. Staff were knowledgeable about people’s care needs, had qualifications in care and received regular training and updating. Staff were aware of signs of abuse and knew how to report concerns and were confident these would be investigated.

People were supported to maintain their health and to access ongoing support from health care services. They received their prescribed medicines in a safe way. Health and social care professionals gave us positive feedback about the care and support provided for people. People were very complimentary about the food choices available at the home. Staff supported people with poor appetites who needed encouragement to eat and drink, including offering regular snacks and meal alternatives.

People were offered day to day choices and staff sought people’s consent for care and treatment. Staff demonstrated a good understanding of the Mental Capacity Act and the Deprivation of Liberty Safeguards. The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. DoLS provide legal protection for vulnerable people who are, or may become, deprived of their liberty.

The service was well led and promoted a culture that valued each person. People, relatives and staff said the home was well run and they had confidence in the provider and the registered manager. The provider had a range of quality monitoring systems in place, these included audits of medicines and care records, monthly health and safety checks and regular meetings with people, relatives and staff.

We identified one breach of regulations at this inspection. You can see what action we told the provider to take at the back of the full version of the report.

Inspection carried out on 19, 20 August 2014

During a routine inspection

There were 26 people living at Hill House at the time of this inspection. We saw the majority of people and spoke with 14 people in some depth to hear about their experience of living there. We also looked at the care records of three people. We spoke with three relatives, four health and social care professionals and seven members of staff including the registered manager.

We considered our inspection findings to answer questions we always ask;

Is the service safe?

Is the service effective?

Is the service caring?

Is the service well led?

This is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

The service was not following the Mental Capacity Act 2005 for people who lacked capacity to make a decision. The provider had not made an application under the Mental Capacity Act Deprivation of Liberty Safeguards for one person, even though their liberty may have been restricted.

People were not always protected against the risks of unsafe or inappropriate care because the planning and delivery of care did not always meet people's individual needs. Where needs had changed, the care plan and risk assessment did not fully reflect the changes or provide guidance to staff to ensure a consistent approach to the delivery of care and support.

All the people we spoke with who lived at the home said that they felt safe and did not have any concerns about abuse or bullying. One person told us, �My falls are non-existent since moving here. I do feel safer here�. Another commented, �No-one tells me what to do or pushes me around�. People told us their care was never rushed.

The three relatives we spoke to also said that they were not concerned about their loved ones� safety at the home. One commented, �It is a relief to know X is well looked after�. One health professional told us, �We have never seen any practice which concerns us�.

People who used the service, staff and visitors were protected against the risks of unsafe or unsuitable premises. We found all areas, communal areas and private bedrooms, were in good decorative order, well maintained, fully accessible, and clean and free from odours.

We found there were effective recruitment and selection processes in place when we checked staff files.

Although the home had experienced some staff shortages due to sickness there was no evidence that people�s immediate care and support needs had not been met as a result. This was due to the effective team work and dedication of the staff.

Is the service effective?

Staff were provided with training to ensure they had the skills to meet people's needs.

New staff received induction training when they started work to ensure they worked safely with people and fully understood their roles and responsibilities.

People living at the home and their relatives told us they were happy with the care and support staff provided and people's needs were met.

Staff had a good understanding of most people's care and support needs and they knew how to meet them and avoid unnecessary risks.

External health and social care professionals told us the service worked well with them. They said there was effective communication which promoted the health and wellbeing of people at the home.

Is the service caring?

We saw staff offering care and support to people throughout the inspection. Staff treated people with respect and their approach was friendly and supportive.

We spoke with 14 people. All confirmed that they were happy with the care and support provided. They said, �I have made friends here. It is very nice. It is home now�; �Staff have the patience of a saint. The majority of staff are very kind and considerate� and �It is very nice here, I'm happy".

We spoke with three relatives. They said they were happy with the care and support their loved ones received. Comments included, "X�s mobility has improved greatly since moving here thanks to the patience and encouragement of staff�, and �The staff are very kind and caring. The home is wonderful�� Visiting professionals told us, �Staff are always mindful of people�s privacy and dignity. We see them knocking on doors. They speak with people respectfully� and �Staff are very attentive�.

Is the service responsive?

People's preferences and interests had been recorded and care and support had been provided in accordance with people's wishes. People were able to join in with a range of activities which they enjoyed and found interesting.

We observed staff responding to people�s requests for assistance in a timely way. We saw staff helping people with their daily activities such as personal care and social activities. Care and support was delivered as requested. This showed that staff were responsive, professional and respectful towards people living at the home.

Records showed health professionals such as GPs, community nurses, speech and language therapists and dieticians were contacted when the service had concerns about people�s health.

Is the service well-led?

People using the service, their relatives and visiting health and social care professionals told us they felt the service was well run and managed. All those spoken with had confidence in the manager of the home. Comments included, �You can speak with the manager about any concerns and she listens�; I have confidence in the manager. I feel the overall standard of care is very good�; and �This is a well-run place. It is very popular with our patients and I would recommend it to people�.

The manager and provider monitored the quality of the service provided by completing regular audits of medicines management, care records and infection control. They evaluated these audits and created action plans for improvement, when improvements were needed.

People living at Hill House were involved in the assessment and monitoring of the quality of service. The results from the last quality survey showed high satisfaction scores were achieved for all aspects of the service.

Records showed that staff recorded incidents that happened. The manager used this information to monitor and investigate the majority of incidents. Appropriate action was taken where necessary to reduce the risk of them happening again.

Inspection carried out on 19 November 2013

During a routine inspection

Hill House provide care and support for frail older people. There were 26 people living at the home when we visited. We spoke with 12 people who lived at the home and a visitor and we looked at four people�s care records. We also spoke with seven staff, the registered manager, a voluntary worker and a district nurse who visited the home regularly.

One person said, �there is an air of general cheerfulness about the home�. Another person said, �staff are very good, they come quickly if I need help�. A third person said the best thing about the home is �being looked after�.

Since we last visited, communal areas of the home had been refurbished and redecorated and some bathroom areas upgraded. People were very pleased with the improvements made. The registered manager told us how mood boards were used to consult with people about the colour schemes and fabrics proposed for each room.

People were involved and consulted in all decisions made about them. People told us they were very satisfied with the care provided and said staff treated them with dignity and respect. We found people were given their medicines when they needed them and in a safe way. Staff were supported to provide appropriate care and treatment to people through regular training and supervision.

Inspection carried out on 14 November 2012

During a routine inspection

Hill House provides care and support for frail older people, some people had dementia. We talked with eight people who lived at the home, seven staff and three relatives. Some people had communication difficulties; this meant they could not specifically tell us what it was like to live at the home.

The people living in the home told us they liked the home and were happy with the care being provided by the staff. One person who lived in the home said �the home is very clean and cheerful� and �It�s so nice living here�. Whilst a visitor told us that staff were �responsive and responsible.

We found that people were listened to before and during their move into the home and their comments were acted upon.

People told us their care and support met their needs and that staff treated them with respect.

People living in the home told us they felt safe and the people visiting the home confirmed that they felt their relatives were safe and well cared for.

We found the home clean and tidy and saw that people were cared for in a clean, hygienic environment.

We followed up concerns about staffing levels in the home; on the evidence available to us we found there were enough staff to meet the current needs of people living in the home.

The provider had robust systems in place to regularly assess and monitor the quality of services that people received.