North Hill House

We found the following examples of good practice.

The registered manager was communicating with people, staff and family members regularly to make sure everyone had an understanding of procedures and precautions being taken, and how to keep people safe. The registered manager worked with the nurses, care staff and housekeeping teams to ensure infection prevention and control measures were followed.

The service was following current guidance in relation to visiting care homes during outbreaks of COVID-19. There were no current essential care givers [A relative or friend who may provide emotional support, or be there to support, when care tasks being carried out, are beneficial to the person’s wellbeing]. Where people were in receipt of end of life care visitors were not restricted. Visits to other people were arranged by appointment and took place in people’s rooms rather than communal areas.

The service had a committed staff team to ensure people received care and support in a safe and hygienic environment. People were supported in the service in accordance with national guidance. The staff team supported people and their relatives to understand the policies and procedures surrounding protection against COVID-19.

Additional cleaning protocols were in place to ensure all high touch points were regularly sanitised. We spoke with the head of housekeeping and looked at cleaning schedules and audits which showed additional systems had been added to increase infection control procedures during COVID-19 pandemic.

Personal protective equipment (PPE) was available to all staff and visitors. Staff and people living at the service were regularly tested for COVID-19.

We spoke with two staff members who confirmed they had received all the necessary vaccinations to work in the care sector. They told us the registered manager kept them updated on any changes to guidance and they had received training in COVID-19 and infection control procedures. They told us, “It’s all taken very seriously” and “We work well as a team and are very aware of the importance of making sure systems are followed.”

We spoke with two relatives who were satisfied with the way their family members were cared for. Comments included, “I have total piece of mind,” “[Person’s name] is very well looked after. I have no concerns at all,” “Nothing is too much trouble. I know [person’s name] is safe at North Hill House” and “I have been able to visit. Is all done professionally.”

North Hill House is a 'care home' that provides personal and nursing care plus accommodation for a maximum of 35 adults, of all ages, with a range of health care needs and physical disabilities. At the time of the inspection 34 people were living at the service.

People’s experience of using this service and what we found

Since the last inspection improvements had been made to the way medicines were being managed. Improvements had been made to the recording of when people’s medicines were given, stock control, medicines audits and medicines care plans. There was a system to record and act on any errors. We were assured records and systems were being maintained for the safe management of medicines.

Improvements had been made to the way people’s care and support were being reported. A review of all care planning systems had taken place. Improvements had been made in all areas of care planning, delivery and review. Staff had a clear understanding of individual needs and responses. We were assured risks were identified and staff had guidance to help them support people to reduce the risk of avoidable harm.

Since the last inspection improvements had been made to governance systems. The management structure had been reviewed and changes made. There were individual responsibilities to ensure a more cohesive overview of the service. The managers had reflected on previous failings and responded by using the collective skill set of the management team to improve all areas. At this inspection we found the assessing and monitoring of the safety and quality of the service had significantly improved. There was now a robust auditing system for the provider and manager to have oversight of the service. We were assured governance systems were effective in the management of the service.

Staff were recruited safely. Staffing levels had been reviewed and significantly increased. This meant people were receiving care and support in a timely manner. Staff were visible in all areas of the service throughout the inspection. Call bells were responded to promptly. The increase in staffing levels meant there was no reliance on the use of agency staff.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Cleaning and infection control procedures had been updated in line with Covid-19 guidance to help protect people, visitors and staff from the risk of infection. Arrangements were in place to support visitors and residents to see each other in a safe area of the home. Staff changed into uniform in the service and changed prior to leaving to help with infection control.

The service had suitable safeguarding systems in place, and staff knew how to recognise and what to do if they suspected abuse was occurring.

Rating at last inspection and update

The service was previously rated Requires Improvement for the key questions of Effective, and Well Led (report published 13 March 2019). Two breaches of regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were identified. They were repeated breaches from the previous inspection, although we found the seriousness and risks associated with the breaches had been reduced.

Following the March 2019 inspection, we met with the provider to discuss the shortcomings of the service and how they would be addressed. The provider completed an action plan to show what they would do and by when to improve. We returned and inspected the service on 02 March 2020. At that inspection we found improvements had been made and the provider had complied with some of the breaches in regulation. The service was rated Requires Improvement for the key questions of Safe, Responsive and Well Led (report published 01 April 2020). Two breaches of regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were identified. We asked the provider to complete an action plan to show what they would do and by when to improve.

At this inspection enough improvement had been made and the breaches of regulation had been met.

Why we inspected

The inspection was carried out to follow up on the action we told the provider to take at the last inspections. As a result, we carried out this focused inspection to review the key questions of Safe, Responsive and Well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the caring and effective key questions and therefore we did not inspect those key questions. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has improved to Good. This is based on the findings at this inspection.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for North Hill on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

North Hill House is a ‘care home’ that provides personal and nursing care plus accommodation for a maximum of 35 adults, of all ages, with a range of health care needs and physical disabilities. At the time of the inspection 31 people were living at the service.

Since the last inspection the service had increased the numbers of people it could support from 31 to 35 people. All structural building works had been completed. People have their own bedroom with en-suite facilities, there is one double room available if people request this. People have access to communal lounges, a dining area and garden.

People’s experience of using this service and what we found

Since the last inspection the provider had still not fully addressed non-compliance in the area of governance, and continued to develop, implement and embed new records and systems to improve the quality of the service. The provider had implemented a framework for quality checks, but this had not picked up many of the issues we observed. For example, due to the different formats of care plans they varied in the quality of information and were not always completed in a timely manner. We also found failings in other records such as risk assessments and medicine records. The lack of maintaining accurate care records meant that staff did not have information, direction or guidance in how to meet people’s needs.

Health and social care professionals confirmed they had seen some positive changes to the service and people’s care needs were being met but records still required improvement.

Since the last inspection a senior member of staff was allocated the tasks of overseeing staff training, supervision and appraisal. Staff told us and records demonstrated that staff were now in receipt of up to date training and support.

The homes manager and provider had been working with the local authority Quality Improvement team and an external consultant to embed positive changes.

The management team encouraged staff to be more involved in raising ideas in how the service could run better and had recently set up ‘project groups’ to look at how the home was run and how it could be improved.

Staff morale was good, and everyone was committed to ensuring people received care and support based on their preferences and choices.

People told us they felt safe and liked living at North Hill House, enjoyed the range of activities and felt well cared for. People said they were always treated with respect. Care staff were eager to be involved in the social aspects of people's lives, which demonstrated their commitment to people's overall wellbeing.

Health and social care professionals were complimentary about the care that people received at North Hill House.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff recruitment processes and staffing levels ensured people’s needs were met. There was time for people to have social interaction and activity with staff. Staff knew how to keep people safe from harm.

People were supported to access healthcare services, staff recognised changes in people's health, and sought professional advice appropriately.

People were involved in menu planning and staff encouraged them to eat a well-balanced diet and make healthy eating choices.

People received support from staff who cared about them. People were supported to express their views in the way they wanted to. People and their families were given information about how to complain and details of the complaint’s procedure were displayed at the service. The management and staff knew people well and worked together to help ensure people received a good service.

People, their relatives and staff told us the management of the service were hands on, approachable and listened when any concerns or ideas were raised.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The service was previously rated Requires Improvement for the key questions of Safe, Effective, Responsive and Well Led (report published 18 April 2018). Five breaches of regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were identified. We asked the provider to complete an action plan to show what they would do and by when to improve.

We returned and inspected the service on 24 January 2019. At this inspection we found improvements had been made and the provider had complied with some of the breaches in regulation. The service was rated Requires Improvement for the key questions of Effective, and Well Led (report published 13 March 2019). Two breaches of regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were identified. They were repeated breaches from the previous inspection, although we found the seriousness and risks associated with the breaches had been reduced.

We met with the provider to discuss the shortcomings of the service and how they would be addressed. The provider completed an action plan to show what they would do and by when to improve.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement/improvement action we have told the provider to take.

At this inspection we found some improvements had been made. This report identified that the service remains an overall rating of Requires Improvement for the key questions of Safe, Responsive and Well Led. We have identified a continued breach in relation to governance and that the provider had not maintained accurate records of the care and treatment provided to people. We identified a new breach in that whilst we found no evidence that people had been harmed, systems were either not in place or robust enough to demonstrate safety was effectively managed. This placed people at risk of harm.

You can see what action we have asked the provider to take at the end of this full report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

What life is like for people using this service:

Since our last inspection the provider has been more visible in the service and reviewed how the service was run. Changes were made to improve the quality of care for people and staff at the service. Staff now had delegated roles and responsibilities so were more accountable for the quality of care they provided. The management team had worked as a strong team to mentor and empower the staff to make improvements to the support people received.

Checks had been completed to help the provider understand if improvements were being made. The checks did not always highlight areas for improvement, or where they did we saw action plans were not recorded effectively. These systems needed to work better to ensure safety and

quality for people.

People, their relatives and the staff all told us they felt more confident in the leadership and management of the service. Good staffing levels afforded people responsive and dignified support.

Staff morale was good and everyone was committed to ensuring people received care and support based on their preferences and choices. People told us they felt safe, and liked living at North hill house and enjoyed the range of activities and felt well cared for. People said they were always treated with respect. Care staff were eager to be involved in the social aspects of people's lives, which demonstrated their commitment to people's overall wellbeing.

Positive changes were seen at this inspection and the motivation for continuous improvement was demonstrated by the staff team within the service. More robust systems would support the provider to make further change to sustain improvements made.

More information is in Detailed Findings below

Rating at last inspection: Requires Improvement (report published 19 April 2018)

Why we inspected: This was a planned inspection based on the rating at the last inspection. At our last inspection we rated the service Requires Improvement and found the service was in breach of the regulations in relation to person centred care, safe care and treatment, staffing, absence of notifications of incidents and good governance. As a result, we issued five requirement notices. We subsequently met with the provider to check action was being taken to improve the service.

At this inspection we found that the provider had complied with some of the breaches of regulation, in the areas of person centred care and notifications of incidents were now reported. We also found that some improvements had been made to other breaches of regulation in the areas of staffing and good governance. We acknowledge that the care for people had improved and people were at less risk. However, there had been insufficient time for these changes to be fully embedded to ensure long term sustainability, hence the rating remains Requires Improvement.

Enforcement/improvement action we have told the provider to take.

Please see the ‘action we have told the provider to take’ section towards the end of the report.

Follow up: We will carry out a further focused inspection, in line with our inspection programme, to check improvements have been made to ensure the service is meeting the regulations. We will continue to monitor intelligence we receive about the service. If any concerning information is received we may inspect sooner

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

North Hill Nursing home provides accommodation. Some bedrooms are on the ground floor where communal areas are also present. The remaining bedrooms are on the first floor which is served by a lift. Staff are present on both floors of the home at all times to ensure people’s needs are met.

This service is owned by a sole provider and, as the ‘registered person’, the provider is responsible for the day-to-day running of the service. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

We carried out this unannounced inspection on 19 February 2018. At the last inspection, in September 2015, the service was rated Good. At this inspection we found the service to have an overall rating of Requires Improvement.

Prior to the inspection we received three anonymous whistleblowing concerns regarding the service. These were in relation to staff attitudes, training and management approach. The majority of staff told us they did not feel able to raise concerns with the management team. The provider and charge nurse were aware that there was low morale in the staff team. They held a staff meeting where it was acknowledged that there was lack of team work and that staff were not completing tasks in a timely or appropriate manner. Whilst the issues were acknowledged and addressed by managers, some staff thought there was no action plan from the management team in how to move this forward for the benefit of staff or the people they supported.

From this inspection we found inconsistencies in how management addressed issues with staff conduct. There was limited or no documentation to evidence if the staff members conduct had been raised with the individual, how it had been addressed and what action was to be taken. This meant there was a lack of confidence in how the management team addressed staffing issues which could impact on the staff team and on the people they supported.

We also identified there was no robust system of effective auditing in place and therefore the provider and charge nurse were unable to identify or address areas of significant concern. For example, we found that care plans were not in place for one person at the service, and that care plans generally were not up to date to reflect people’s current care needs. Risk assessments, for example falls assessment, had not been reviewed when people’s needs had changed, to see what preventive measures needed to be put in place to minimise the potential for further falls. We concluded that people’s care plans did not provide staff with sufficient accurate information to enable them to meet people’s current care needs.

People were supported to take their medicines by nursing staff who had been appropriately trained. However, medicines management was not fully robust. The stock of medicines that had been prescribed for people did not tally with records held at the service. This meant that the service could not account for all medicines held at the service or be confident that people’s medicines were being stored and administered safely.

We found recruitment processes were not followed consistently. We also found that staff induction, supervision and appraisal had not occurred for some time. In addition staff training was not up to date. Therefore staff were not being supported to maintain and develop their skills in line with current best practice.

Some people needed help from staff to move from one place to another, with the use of a hoist and a sling. At the last inspection we found that some slings were shared between people, which presented an infection control risk. At this inspection we found this remained the case. We recommended that people need to be allocated their own individually assessed sling, suitable for their needs to reduce the risk of cross infection.

We identified that the provider had not notified us of significant events at the service. The provider is required by law to submit notifications to CQC of significant events such as injury or any safeguarding concerns. We found the service had not submitted statutory notifications as required since the last inspection in 2015. This demonstrated the provider continued to not act in accordance with their legal responsibilities.

Following feedback to the provider and charge nurse they stated they wanted to ensure that the failures of the service were addressed. They have shown since the inspection a commitment to commence addressing some of the concerns raised above. For example contacting us for guidance and the administrator had submitted notifications as required by law

The registered provider had identified they did not have appropriate administration or auditing systems in place. In November 2017 they introduced an administrative/ reception post in the aim that they would assist the charge nurse with the administration in the service. Since their appointment some systems had been implemented, such as a supervision chart

People were positive about the care they received. Comments from people included “I think I am fortunate to have found a place like this”, “I am quite happy here”, “The staff do come to your room and sit and talk to you. It is nice that they will come and talk to you” and “Staff are pretty good.” Relatives echoed these views.

During the inspection we saw people’s needs were usually met quickly. We heard bells ringing during the inspection and these were responded to effectively. People and relatives felt that there was sufficient staff on duty.

The service was undergoing major internal building works as it was extending the number of rooms in the service, and upgrading others. Due to this there was disruption to the service but management were keen to minimise disruption to the people that lived there. Despite the on-going internal building works the domestic team worked tirelessly to ensure that all areas of the service remained clean and tidy.

The catering staff had a good knowledge of people’s dietary needs and catered for them appropriately. People had access to healthcare services and received on-going healthcare support.

People and their families were given information about how to complain and details of the complaints procedure were displayed in the service. Some people told us they knew how to raise a concern and they would be comfortable doing so.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014. You can see the action we have told the provider to take at the end of this report.

North Hill House is a care home that can accommodate up to 28 older people. At the time of our inspection there were 25 people living at the service.

This service is owned by a sole provider and, as the ‘registered person’, the provider is responsible for the day-to-day running of the service. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

People told us they felt safe living at North Hill House and with the staff who supported them. Comments from people and their relatives included, “No concerns, very good” and “I am very happy living here.” A healthcare professional said, “It’s brilliant. Everyone seems happy and chatty when I visit.”

During our inspection there was a relaxed and friendly atmosphere at the service. We observed people had a good relationship with staff and staff interacted with people in a caring and respectful manner. Relatives said, “They [staff] do everything possible for [person’s name]” and “Staff are lovely. Really caring of me and [person’s name].”

People took part in a range of group and individual activities of their choice. Where people stayed in their rooms, either through their choice or because they were cared for in bed, staff spent one-to-one time with them. This helped to prevent them from becoming socially isolated and promoted their emotional well-being. There were sufficient numbers of suitably qualified staff on duty and staffing levels were adjusted to meet people’s changing needs and wishes.

Staff completed a thorough recruitment process to ensure they had the appropriate skills and knowledge. Staff knew how to recognise and report the signs of abuse.

People had access to healthcare services such as occupational therapists, GPs, chiropodists and dieticians. Relatives told us they were confident that the service could meet people’s health needs and they were always kept informed if their relative was unwell or a doctor was called.

Staff supported people to maintain a balanced diet appropriate to their dietary needs and preferences. A newly recruited ‘hotel service manager’ had sought people’s views about the meals provided and, as a result of the comments received, menus had been changed. One person told us, “The catering wasn’t so good. Since [name of hotel service manager] joined it has improved a lot.”

Care records accurately reflected people’s care and support needs. Details of how people wished to be supported were individualised and provided clear information to enable staff to provide appropriate and effective support. Any risks in relation to people’s care and support were identified and appropriately managed.

Management and staff had a good understanding of the Mental Capacity Act 2005 (MCA). Where people did not have the capacity to make certain decisions the management and staff acted in accordance with legal requirements under the MCA. Staff applied the principles of the MCA in the way they cared for people and told us they always assumed people had mental capacity.

People and their families were given information about how to complain. People told us they knew how to raise a concern and they would be comfortable doing so. There was a management structure in the service which provided clear lines of responsibility and accountability. Staff had a positive attitude and the management team provided strong leadership and led by example. Staff said, “Communication is good” and “It’s absolutely lovely working here.”

Effective quality assurance systems were in place to make sure that any areas for improvement were identified and addressed. Management were visible in the service and regularly observed and talked to people to check if they were happy and safe living at North Hill House.

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and the staff told us.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

During our inspection of North Hill Nursing Home we saw evidence to support a judgement that this service was safe.

People were treated with dignity and respect by the staff. During our inspection we spoke with eight people living in the home and six visiting relatives. People told us they were very happy living in the home and they felt safe. One person told us 'I am very happy here'. Relatives told us 'X is very happy here' and 'I can't recommend the home enough'.

Care plans were personalised to the individual and gave clear guidance for staff to follow to meet people's needs. Care staff told us the nurses were good at updating them about people's health needs and all staff worked together well to ensure people's needs were met.

People were safe because staff knew what to do when safeguarding concerns were raised and they followed guidance.

We saw North Hill Nursing Home understood the legal requirements of the Mental Capacity Act 2005 and the associated Deprivation of Liberty Safeguards.

We found there were enough qualified, skilled and experienced staff to meet people's needs.

Is the service effective?

During our inspection of North Hill Nursing Home we saw evidence to support a judgement that this service was effective.

People's health and care needs were assessed and mobility and equipment needs had been identified in care plans where required. Staff we spoke with and observed showed they had good knowledge of the people they supported.

We spoke with six visitors and they all confirmed they were able to visit the home whenever they wished. One relative told us they provided personal care for the person when they visited and the home had supported them to do this.

Is the service caring?

During our inspection of North Hill Nursing Home we saw evidence to support a judgement that this service was caring.

People's individual care plans recorded their choices and preferred routines for assistance with their personal care and daily living. We saw staff provided support in accordance with people's wishes.

Everyone we spoke with told us staff were caring and attentive to their needs. One person told us 'they [staff] are wonderful'. Relatives told us 'there is good, kind interaction by staff' and 'I am happy for staff to look after X'. We observed staff responded to people in a kind and sensitive manner.

Is the service responsive?

During our inspection of North Hill Nursing Home we saw evidence to support a judgement that this service was responsive.

The home employed an activities co-ordinator, who worked at least three days a week, to facilitate group activities such as; card games, bingo and darts. Another worker was allocated to spend one day a week talking and reading to people individually who were bed bound or chose to stay in their rooms. This meant that activities were provided to support people's individual needs.

North Hill Nursing Home gave clear information to people about how to complain. The home had not received any complaints in the last year. We saw that because of the open culture of the home, people were happy to give feedback or raise concerns as soon as situations occurred. One relative told us whenever they raised any concerns these were listened to and dealt with promptly. This meant that any concerns were dealt with quickly and resolved without the need to formally complain.

Is the service well-led?

During our inspection of North Hill Nursing Home we saw evidence to support a judgement that this service was well-led.

The home worked with other services to ensure people's health needs were met. This included professionals such as GPs, dieticians, speech and language therapists and tissue viability nurses.

It was clear from people and relatives we spoke with that the manager and owner were visible in the home and involved people in decisions made about the running of the home. Staff we spoke with told us the management team were very approachable and welcomed any ideas or suggestions from staff.

Quality assurance systems were in place to monitor the service being provided and where shortfalls were identified these were addressed. At a result the quality of the service continuously improved.

This was a planned inspection to follow up a compliance action made at the last inspection about assessing and monitoring the quality of the service.

We saw care plans were detailed and gave direction as to the care and support people needed. They had been regularly reviewed.

The home was clean and hygienic whilst remaining homely.

The home was well maintained and there was an ongoing improvement and redecorating plan in place.

We saw there was enough qualified, skilled and experienced staff to meet people's nursing, care and social needs.

People who lived at North Hill House told us staff were helpful. One person said 'everybody is nice here and I get the help I want'. During our inspection we saw and heard staff interacted with the people in a friendly and professional manner.

Although each person had a care plan they were not detailed enough to direct as to the care and support each person needed.

People told us they enjoyed the meals. We saw people who needed help with their meals received assistance in a discreet manner. We saw specialist diets were catered for and managed well.

We were shown there was a robust system in place to obtain medicines from the pharmacy for people who lived in the home. This meant that people received the correct medication at the correct time.

Everyone we spoke with was satisfied with the service they received. We saw the staff training programme was much improved since our last visit. Staff told us there was regular access to training either on line, by external providers or in house.

There was no satisfactory formal quality assurance system in place. This meant it was not clear how the ongoing quality of the service was managed. We saw the provider knew the people that used the service and they, as well as the staff, were happy to approach him about anything they wished to discuss.