Hillsdon Nursing Home

We found the following examples of good practice.

Rooms around the home looked and smelt clean and hygienic. People who used the service told us the home was kept clean. One person told us, “They’re always hoovering.”

Washing at very high temperatures as per infection control guidance for bedding and towels, use of alginate bags for foul linen.

When welcoming family and professional visitors and contractors, the service measured their oxygen level as well as doing the usual symptom questionnaire, lateral flow tests and temperature checks. This is easily done through a gadget that fits on a person’s fingertip. A low oxygen level can be an indicator of a respiratory infection such as COVID-19.

Although there was no longer a requirement for people to isolate following a visit out of the home, the service would take their temperature on return and their oxygen level would be monitored for 48 hours.

As a result of local authority and NHS commissioning arrangements, people were all admitted to the service from hospital, where they had the necessary testing for coronavirus.

Personal protective equipment (PPE), such as disposable gloves, masks and aprons, and hand sanitiser was readily available outside people’s rooms. Each room had a clinical waste disposal facility just inside the door, so staff could remove PPE and cleanse their hands on leaving the room.

A person who used the service told us staff always wore PPE when providing care. The person said they were used to seeing just half of staff faces.

New double glazing had been installed to allow for good ventilation without having to open large windows above ground floor level, which could be unsafe.

The service had acquired a tablet computer to enable people to keep in touch with their friends and family, if physical visiting was not practical or possible. Staff also supported people to keep in touch by phone or letter if they preferred.

Hillsdon Nursing Home is registered to accommodate a maximum of 21 people who require both nursing and personal care. There were 18 people, all requiring nursing care, living at the home at the time of our inspection.

The home was led by 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.

At our last inspection in September 2018, which was a focused inspection, we found the home had made improvements we required from the previous inspection in June 2017 and the service was rated as good. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

Is the service safe?

People were protected from potential abuse and avoidable harm. This was because staff had received training and were knowledgeable about recognising and reporting different signs of abuse. There were enough appropriately qualified staff available on each shift to ensure people were cared and supported safely. Risks to people had been assessed and were well managed. Medicines were managed safely and there were effective systems in place. People were protected by the prevention and control of infection. The registered manager reviewed and learned from incidents when things went wrong.

Is the service effective?

People’s needs were fully assessed and they had access to health care professionals who worked in collaboration with the staff at the home. Staff received training to meet the individual needs of people. Staff told us they felt supported to carry out their roles. There was good team moral and staff were committed to enhancing the lives of people at the home. People were supported to have maximum choice and control of their lives. Staff supported them in the least restrictive way possible with policies and systems to support this practice. People were satisfied with the standard of food provided and told us there was good choice in menus. People's independence and wellbeing was enhanced by the environment of the home.

Is the service caring?

There was an open, friendly and homely atmosphere at Hillsdon. People and relatives all said the staff team were kind and caring. Staff were knowledgeable and understood the care people needed. People were treated with dignity and respect and were supported to make their own choices.

Is the service responsive?

People received good personalised care and treatment as up to date care plans were in place for each individual. Staff took the time to get to know people, their life and social histories. This ensured good outcomes for people. Activities were provided based on people’s interests and past experiences. There had been no complaints raised about the service since our last inspection.

Is the service well led?

The service was led by the registered manager and Nominated Individual for the company. Staff told us they were approachable whilst at the same time setting high standards. People, their relatives and staff were consulted and involved in their care and support. There was a programme of quality checks and audits to ensure the quality of the service was maintained.

We undertook an unannounced focussed inspection on 18 December 2017, which was carried out by one inspector. The aim of the inspection was to follow-up on a Warning Notice that was issued at the last inspection in June 2017. The Warning Notice was issued as the home was not compliant with requirements of The Mental Capacity Act 2005. At the last inspection we also found there were improvements that could be made in respect to safety issues and good governance. We therefore inspected the service against the related three key questions. No risks, concerns or significant improvement were identified in the remaining Key Questions through our on-going monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

At this inspection improvements had been made overall and staff reported that the morale was much higher.

Staffing levels were suitable to meet people’s needs.

There was monitoring of accidents and systems to make sure actions were followed up and any trends identified.

Staff were recruited in line with robust policies and all the necessary checks had been carried out.

Medicines were managed safely and people received the medicines prescribed by their doctor.

People’s needs had been assessed and risks identified for care delivery as well as safety of the premises.

The home complied with infection control standards.

Staff were supported through supervision and annual appraisal.

The home was working collaboratively with health services so that people’ needs were met.

The home provided a good standard of food with people having choice of what they wanted to eat and their individual needs catered for.

There were auditing and monitoring systems being followed seeking overall improvement. Overall the home was well-managed.

This was an unannounced comprehensive inspection carried out by two inspectors on 9 June 2017 and one inspector on 22 June 2017. We last inspected the home in November 2016 when we found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. We carried out this comprehensive inspection to follow-up on these requirements and because of concerns that had been raised.

The registered persons had not taken action to fully address all the areas for improvement outlined at our previous inspection. At this inspection we identified two breaches of the regulations that had not been met from the last inspection; namely compliance with The Mental Capacity Act and good governance.

There was a registered manager at the home at the time of the inspection. 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.

An environmental risk assessment and action plan had been carried out, as required at our last inspection; however, on being shown around the home on the first day of the inspection, we identified hazards where action could have been taken to make the environment safer for people. These issues were addressed by the second day of the inspection.

There had been improvement in following the procedures for the recruitment of new members of staff but one person’s employment history should have been more robust.

With regards to compliance with the requirements of the Mental capacity Act 2005 (MCA), there was still a need for better understanding and implementation.

There was a positive culture and morale at the home, however there was still a need for better overall assessment and management of risk in the running of the home.

Staff had been trained in safeguarding adults and were knowledgeable in this field.

Risk assessments had been completed to make sure that care and support was delivered safely with action taken to minimise identified hazards.

Accidents and incidents were monitored to look for any trends where action could be taken to reduce likelihood of recurrence.

There were sufficient staff employed at the home to meet the needs of people accommodated.

Medicines were ordered, stored, administered and disposed of safely and overall there was good management of people’s medicines.

The staff team were both knowledgeable and well trained and there were induction systems in place for any new staff.

Staff were well-supported through supervision sessions with a line manager and an annual performance review.

People were provided with a good standard of food, appropriate to their needs. Action was taken in circumstances where people had lost weight.

Relatives, staff and people were positive about the standards of care provided at Hillsdon Nursing Home. People were treated compassionately as individuals with staff knowing people’s needs.

People’s care and support needs had been thoroughly assessed and care plans put in place to inform staff of how to care for people. The plans were person centred, covered people’s overall needs and were up to date and accurate.

A programme of activities was provided to keep people meaningfully occupied.

There were complaint systems in place and people were aware of how to make a complaint.

Should people need to transfer to another service, systems were in place to make sure that important information would be passed on.

Systems were not fully effective in monitoring the quality of service provided to people.

Hillsdon is a nursing home for up to 21 mainly older people and there were 19 people living there when we visited. Bedrooms are situated on the ground and first floors of the building. Most bedrooms are single bedrooms, but two are shared.

The home is run by its owners, one of whom is its 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 were treated with kindness and respect and staff maintained their dignity. Their needs were assessed and kept under review. They received personalised care that met their individual needs and respected their preferences. Their health was monitored and referrals were made where necessary to doctors and other health and social care professionals. Medicines were managed safely.

The service had attained Gold Standards Framework accreditation, a nationally recognised standard, for the quality of its end of life care.

People spoke positively about the food. They received the support they needed to meet their nutrition and hydration needs.

Staff morale was good. They were well supported through training and supervision to meet people’s needs. There were sufficient staff on duty to meet people’s needs. However, many people were highly dependent, requiring two staff at a time for aspects of care such as moving and handling. Two people in the lounge often did not have staff present to support them, particularly in the morning. We have made a recommendation regarding the deployment of staff in communal areas.

There were shortfalls in the assessment and management of some risks, in particular the risks associated with using bed rails. Many people had bed rails raised when they were in bed, yet for the people whose records we viewed the risks of these had not been assessed, nor had consent been obtained or a best interests decision made in line with the requirements of the Mental Capacity Act 2005. Oxygen cylinders had not been stored safely. You can see what action we told the provider to take at the back of the full version of the report.

Whilst many areas of the premises were visibly clean, some areas were grubby with debris and cobwebs. Some paintwork and upholstery was not intact and so would be difficult to clean effectively. An appropriate standard of hygiene for a nursing home was not maintained in the laundry. The service had not undertaken its own infection control audits, relying instead on monitoring visits from the local authority and Clinical Commissioning Group, who had advised the service of shortfalls. You can see what action we told the provider to take at the back of the full version of the report.

Suitable employment references were not obtained for some staff. The information required to be retained in respect of staff, such as a full employment history with a satisfactory written explanation of any gaps, had not been kept. You can see what action we told the provider to take at the back of the full version of the report.

Effective systems were not operating to monitor the quality of service being delivered and the running of the home and to bring about improvements that were needed. Shortfalls identified through external monitoring visits and risks highlighted in a 2014 fire risk assessment had not been addressed. The registered manager had limited time available to attend to management responsibilities because they were rostered to deliver care, covering for long-term staff sickness absence. The registered manager told us some documentation relating to quality assurance and premises safety was locked in the nominated individual’s office. They did not have ready access to records they needed to meet their management responsibilities as manager. You can see what action we told the provider to take at the back of the full version of the report.

The registered manager and nominated individual had notified CQC about most significant events such as deaths. We use information from notifications to monitor the service and ensure they respond appropriately to keep people safe. However, a safeguarding concern raised by the service with the local authority had not been notified. We have made a recommendation regarding the provider reviewing their procedures to ensure they always notify CQC of significant events.

There were 20 people living at the home on the day of our inspection.

The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at. If you want to see the evidence that supports our summary please read the full report.

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 responsive?

' Is the service well-led?

This is a summary of what we found.

Is the service safe?

People were cared for in a clean, hygienic environment. The home was visibly clean and smelt fresh throughout. Furnishings and equipment that had cracked or frayed surfaces had been replaced with items that were intact. The provider had introduced a system for routine checks of infection prevention and control measures.

People who use the service, staff and visitors were protected against the risks of unsafe or unsuitable premises. The cracked tile we saw at our last inspection had been replaced and repairs to a further area of cracked tiles were about to commence. Areas of loose carpet had been secured and a new hall carpet was on order.

Is the service effective?

Where people did not have the capacity to consent to using bed rails, the provider acted in accordance with legal requirements. The provider had assessed people's mental capacity and had recorded a decision in line with the requirements of the Mental Capacity Act 2005 that this would be in the person's best interests.

Is the service caring?

As we were following up on compliance with regulations for obtaining consent, preventing and controlling infection, ensuring the safety of the premises and assessing and monitoring the quality of service provision, we did not look at standards concerned with caring for people. At our last inspection in May 2014 people and their relatives told us that they felt well cared for.

Is the service responsive?

As we were following up on compliance with regulations for obtaining consent, preventing and controlling infection, ensuring the safety of the premises and assessing and monitoring the quality of service provision, we did not look at standards concerned with the responsiveness of the service. At our last inspection in May 2014 we found that the service responded to people's changing needs.

Is the service well-led?

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others. The nominated individual had put in place a system for ensuring that health and safety in the home was audited, through a six monthly risk review with monthly health and safety checks in between.

The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at. If you want to see the evidence that supports our summary please read the full report.

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 responsive?

' Is the service well-led?

Is the service safe?

Whilst most areas of the home were visibly clean, some furnishings and equipment were damaged and so could not be cleaned properly. This meant that people were not all cared for in a clean, hygienic environment.

People who use the service, staff and visitors were not protected against the risks of unsafe or unsuitable premises. Some areas of the home had not been adequately maintained. Parts of the carpet on the first floor landing were not secured and presented a trip hazard. In addition, there was a crack in a tile above the sink in the visitors' toilet. This meant that the area would be difficult to clean properly and could harbour infection. The provider confirmed following the inspection that the carpet had been secured.

The provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others. The provider had not ensured that staff identified, assessed and managed the risks associated with using bed rails.

There were enough qualified, skilled and experienced staff to meet people's needs. One person told us that staff came quickly whenever they requested help and we observed that staff answered call bells promptly. A relative commented that there was 'Definitely a regular staff team' and the staff rotas we examined confirmed this.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DOLS), which apply to care homes. The provider told us they were currently considering how the recent Supreme Court judgement about DOLS affected the home. They said they were awaiting a response from the local authority to a query in relation to DOLS and anticipated that they would be submitting applications for most people living at the home. They agreed to notify us of the outcome of any applications, as the law requires. This showed that the provider was taking action to ensure the home met legal requirements relating to DOLS.

Is the service effective?

People were not asked for their consent for bed rails to be fitted to their beds. Where people did not have the capacity to consent, the provider had not acted in accordance with the requirements of the Mental Capacity Act 2005.

People spoke positively about the care they or the person they visited received. One told us, 'I'm very pleased [person]'s here because the level of care is wonderful.' We observed that staff followed people's care plans, for example setting people's special mattresses correctly to protect them from the risk of pressure sores. All the people we met looked clean and comfortable. They had drinks to hand in suitable cups to enable them to drink safely and independently. They had call bells within their reach and these were answered promptly.

Is the service caring?

People told us that staff treated them or the person they were visiting with respect. One person said, 'They're so friendly and helpful. I feel so safe here' very safe and comfortable.' We observed that staff assisted people in a kind and respectful manner.

Is the service responsive?

The home's management ensured the home would be able to meet people's needs before they moved in. Nurses assessed each person's individual needs when they moved in to the home and used these assessments to devise their care plans. Care plans reflected people's assessed needs and contained clear actions for staff to take so people received the help and support they needed. Assessments and care plans were regularly reviewed and updated as necessary.

Is the service well-led?

Health and safety risks had not all been identified, assessed and managed. There had not been effective checks to ensure that bed rails and their protective covers were being used safely and correctly. Health and safety checks had not identified or addressed the trip hazard posed by a loose carpet on the first floor landing, nor the risk of infection posed by a broken tile in the visitors' toilet and cracked padded bed rail covers.

People who use the service, their representatives and staff were asked for their views about their care and treatment and these were acted on. Everyone we spoke with expressed confidence that they could speak with senior management of the home, who addressed any queries or concerns they had.

Many people living at the home were unable to talk to us. We spoke with two individuals, one of their relatives and three relatives of two other people. We also gathered evidence by observing care, reviewing records, and speaking with the nominated individual, registered manager and a member of staff.

People's privacy, dignity and independence were respected. For example, one individual commented that Hillsdon Nursing Home always felt homely and clean, with no unpleasant smells. People's views and experiences were taken into account in how the service was delivered.

People experienced care, treatment and support that met their needs and protected their rights. We found that people's needs were assessed and care was planned and delivered in line with individual care plans. People were complimentary about the care they or their relatives received.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

People were cared for, or supported by, suitably qualified, skilled and experienced staff.

The provider had an effective system to regularly assess and monitor the quality of service that people receive. They also had an effective system in place to identify, assess and manage risks to people's health, safety and welfare.

We found that the home had purchased new equipment to ensure that food was kept hot and had introduced new systems to evidence that people were given a choice of meals. They had also improved the system for ensuring that people had adequate nutrition and evidencing when additional snacks and supplements were offered. This meant that the home was protecting people from the risks of inadequate nutrition.

The home had also improved the management of people's hydration. We found that a more detailed assessment of each person's daily fluid requirements had been made and that fluid charts were totalled once a day to check that targets had been met or take action where concerns arose. This meant that the home was protecting people from the risks of dehydration.