Hill House

Hill House is a 'care home' providing personal care up to a maximum of 37 people. The service provides care for younger and older adults, some of whom live with dementia, in one adapted building. There were 25 people living in the home on the first day of our inspection, 23 on the second, and 22 people thereafter.

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

The service was not well-led. The provider had failed to carry out their regulatory responsibilities. They did not have effective quality monitoring procedures in place to identify shortfalls and drive improvements in the service people received. This exposed people to significant risk of harm. The provider failed to deliver safe, person-centred care and had not made improvements they said they would make.

The provider did not safeguard or protect people from harm. They had not referred all potential safeguarding events to the local authority in line with protocols. Staff did not ensure people received care and treatment in a safe and effective way. We found multiple failures in the safe use of medicines.

Risks to people's safety were not fully assessed or reduced. Staff did not support people to move safely. Systems were not followed to help maintain people’s skin condition. Staff did not follow the provider’s policy in relation to falls, and emergency healthcare was not sought promptly in line with this. Fire related risks were not well-managed, people had access to substances hazardous to their health, and the home was not clean nor well-maintained. This placed people at risk of harm.

The provider’s systems did not enable staff to effectively identify and manage people's dietary needs. This put people at risk of not receiving sufficient or appropriate food and fluids.

People’s care needs were not effectively assessed or reviewed and care was not planned in line with best practice guidance. Care plans were contradictory and not updated to reflect people’s changing needs. They did not contain enough personalised information to support staff to respond to people’s needs safely and effectively. Gaps in care records meant we could not be assured care had been carried out as planned.

Staff had not received effective training or regular supervision. This resulted in staff not having the skills to meet people's needs and we found multiple areas of poor practice.

People were not always treated with dignity and respect. We saw many missed opportunities for people to be involved in decisions about their care. Opportunities for people to be involved in social engagement and activities were limited. People were not consistently supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

People liked the food and the staff. Some staff interacted with people in a kind and caring way. Relatives told us they felt involved in their family member’s care, and staff kept them up to date if anything changed.

The nominated individual was receptive to our findings and suggestions. They stated a commitment to improving the service through greater oversight and governance to ensure people received safe care that met their needs and wishes. They had started to implement new quality audits during our inspection. However, these needed time to be implemented and to become embedded in practice.

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

Rating at last inspection

The last rating for this service was good (report published 30 May 2018).

Why we inspected

The inspection was prompted in part due to concerns about safeguarding people from harm, safe care, staff training and support, nutrition and hydration, person-centred care, privacy and dignity, poor maintenance and cleanliness, and good governance. We reviewed of the information we held about this service. A decision was made for us to inspect and examine those risks.

We found evidence during this inspection that people were at risk of harm from these concerns. Please see the safe, effective, caring, responsive and well-led sections of this full report.

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 COVID-19 and other infection outbreaks effectively.

Enforcement and Recommendations

We have identified breaches in relation to safeguarding people from abuse, safe care and treatment, staffing, nutrition and hydration, person-centred care, premises and equipment, consent, dignity and respect, and good governance at this inspection

Please see the action we have told the provider to take at the end of this report.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We found the following examples of good practice.

Only essential visits were being facilitated at the time of our inspection such as for end of life care. All visitors to the service had their temperature checked, undertook a COVID-19 test, completed a health questionnaire and were provided with personal protective equipment (PPE).

The service had been providing 'screened' visits for people and their families within a designated room. Visits were by appointment only, with times allocated to avoid potential infection transmission with other visitors and to allow for the visiting area to be thoroughly cleaned between visits.

PPE was placed throughout the service, with ample supplies available. Staff were seen to be maintaining social distance and adhering to the PPE guidance and protective measures in place.

The service was clean and hygienic. Robust cleaning schedules were in place. People's rooms and areas frequently touched by people and staff such as door handles were cleaned regularly and deep cleaning took place weekly. This helped reduce the risk of infections and cross contamination.

The provider had developed policies and procedures in response to the COVID-19 pandemic. Risks to people and staff in relation to their health, safety and wellbeing had been thoroughly assessed.

At our last comprehensive inspection on 1 February 2017, we rated the service good. Following that inspection, we received concerns relating multiple areas of the service. We carried out a focused inspection to look at these concerns on 30 October 2017. We found the service was not meeting the standards we inspected in relation to management and maintenance systems, staffing levels, medicines management and respecting people’s privacy.

At this inspection, we found that they had made the required improvements and were meeting all the standards. However, there were some areas that needed further development. This was in relation to the choice of food offered to people and building maintenance.

The service had a manager who was registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC 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 and associated Regulations about how the service is run.

People were supported in a safe and appropriate way and staff knew how to recognise and report any risks to people’s safety. Medicines were administered in accordance with the prescriber’s instructions. There were sufficient staff who were recruited safely and competent and well supported.

Areas of the building required redecoration. People’s health and nutritional needs were effectively met and monitored. People were provided with a balanced diet and staff were aware of people’s dietary needs. However, choice of meal was sometimes limited.

Staff knew the people they cared for well and understood, and met, their needs. People received care from staff who were trained and well supported. People were supported to access health care when they required it. People’s rights to make decisions about their care were respected. Where people did not have the mental capacity to make decisions, they had been supported in the decision making process.

People were treated with dignity, respect and kindness and were supported in accordance with their preferences and wishes.

People received person centred care in relation to their personal care and support needs. People were supported to access a range of activities, but this was an area for further development.

There was a complaints process that people knew how to use and were confident they would be acted upon. People, relatives, staff and care professionals made positive comments about the running of the service. There were systems in place to monitor the quality of the home, listen to people and value staff. The service worked in partnership with other agencies.

This report only covers our findings in relation to these concerns. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for 'Hill House' on our website at www.cqc.org.uk.

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 is not registered to provide nursing care. Hill House provides a service to up to 37 people in one adapted building.

This unannounced inspection took place on 30 October 2017. There were 18 people receiving a service at that time.

The manager had worked at the service since March 2017. CQC was processing their application to register at the time of our 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.

There were not sufficient numbers of staff at the service at all times to meet people’s needs safely. Staff were only employed after satisfactory pre-employment checks had been obtained.

People were supported to manage their prescribed medicines safely. Staff were aware of the actions to take to report their concerns.

There were systems in place to ensure the building and equipment were maintained.

People’s private space was not always respected and people were not always involved in decisions about the care and support they received. People received care and support from staff who were kind and caring.

Audits of the service were not always effective. There were sufficient resources to ensure the running of the service. The manager was approachable and worked to improve the service.

Further information is in the detailed findings below.

At the last inspection the service was rated Good.

This inspection was undertaken on 1 February 2017 and was unannounced. At the last inspection we found the provider was in breach of one of the regulations that we assessed. This was in relation to the management of people’s medicines. We received an action plan from the provider which detailed the actions that that they were taking to improve the service. During the inspection we found that the required improvements had been made.

At this inspection we found the service remained Good.

People told us they felt safe living in the service. Risks to people were appropriately planned for and managed.

People told us there were enough staff to provide them with support when they needed it.

Staff had received appropriate training, support and development to carry out their role effectively.

People received appropriate support to maintain healthy nutrition and hydration.

The service was meeting the requirements of the Deprivation of Liberty Safeguards (DoLs). People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People told us and we observed that they were treated with kindness by staff who respected their privacy and upheld their dignity.

People were given the opportunity to feed back on the service and their views were acted on.

People received personalised care that met their individual needs. People were given appropriate support and encouragement to access meaningful activities and follow their individual interests.

People told us they knew how to complain and were confident they would be listened to if they wished to make a complaint.

The managers worked hard to create an open, transparent and inclusive atmosphere within the service. People, staff and external health professionals were invited to take part in discussions around shaping the future of the service.

There was a robust quality assurance system in place and shortfalls identified were promptly acted on to improve the service.

Further information is in the detailed findings below

This inspection was unannounced and took place on 13 June 2016. The previous inspection took place on 19 October 2015 and overall was rated as good. However we had received concerning information about the care that was being provided to the people living at Hill House and as a result of this we brought the date of this inspection forward.

The home had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 and associated Regulations about how the service is run.

The CQC monitors the operation of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) which applies to care services. Staff had received training and had an understanding to ensure that where people lacked the capacity to make decisions they were supported to make decisions that were in their best interests. People were only deprived of their liberty when this was lawful.

Medicines were not safely managed and the medicine processes were not effective.

The provider had a robust recruitment process in place and staff were only employed within the home after all essential safety checks had been satisfactorily completed.

Staffing numbers were adequate to ensure people’s care needs were met.

Care plans provided detailed information on how people’s care needs were to be met this had been identified through their quality monitoring system. Staff were aware of people’s needs.

People’s privacy and dignity were respected at all times. Staff sought, and obtained, permission before entering people’s rooms to provide personal care.

People’s health, care and nutritional needs were effectively met. People were provided with a varied, balanced diet and staff were aware of people’s dietary needs. Staff referred people appropriately to healthcare professionals when this was needed.

Wherever possible people or their families were involved in the planning of the care people received.

The provider had an effective complaints process in place which was accessible to people, relatives and others who used or visited the service.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

We spoke with three staff members, four people who lived in the home and viewed a range of documents including the staff rota and staff training records. We undertook a tour of the premises to check on health and safety matters.

SAFE

Staffing levels at the home were satisfactory and people's requests for assistance were met in a timely way. However, we found a number of shortfalls with the premises which compromised people's safety and wellbeing. Cleanliness in the home's laundry was poor. Continued problems with the home's water system meant that some people did not have hot water when they wanted it. We found there were inadequate arrangements for first-aid provision to ensure that staff could deal with a medical emergency.

The provider had, once again, failed to notify us of an important event that affected the welfare, health and safety of people who used the service so that, where needed, action could be taken.

CARING

The level and frequency of activities available to people at the home had reduced considerably since the activities co-ordinator had left. Information about the activities at the home was inaccurate and we found little evidence that the scheduled activities advertised had actually taken place.

We found that improvements were needed to laundry management systems in the home to ensure that people did not wear other people's clothes.

Records of when people's welfare had been checked were not accurate.

During our inspection we spoke with four members of staff, the manager, two visitors and eight people who lived at the home.

We considered our inspection findings to answer questions we always ask: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

This is a summary of what we found:

Is the service caring?

People who lived at the home and the visitors we spoke with told us they were very happy with the care and support that was provided by the staff. We observed people being treated with respect and staff ensured people's dignity was maintained. People were encouraged to be as independent as possible.

Is the service responsive?

We saw that people's needs had been assessed before they moved into the home. We found that care records we looked at were reviewed on a monthly basis and on the whole changes were made to the care plans.

Is the service safe?

During this inspection we looked around the home. We found that communal areas and some bedrooms were in need of decoration as they were looking tired. We were shown an improvement plan, which showed that some communal areas and bedrooms had been highlighted for re-decoration. Whilst it stated 'quotes in place' there were no timescales set for completion. Overall we found the home to be clean and tidy, with one shower room in need of a clean, which the manager addressed during our inspection.

Is the service effective?

People we spoke with were satisfied with the care they received from the staff at Hill House. Staff we spoke with understood people's needs and told us they were well supported to deliver peoples care needs. Care plans gave staff clear guidance on each person's needs.

Is the service well led?

Staff we spoke with told us they enjoyed their job and felt supported to do their jobs. Quality assurance records we looked at showed that although some of them identified some areas for improvement they did not all contain full details as to how these were to be addressed within a timescale. We found that the auditing system could be improved.

If you wish to see the evidence supporting our summary please read the full report.

We found that improvements had been made to people's risk assessments, their care plans and staff were able to tell us how they cared for and supported people.

We had concerns about the quality of information in people's care records during our inspection in May 2013. Although we found that the format had been changed and was easier to read the information did not provide the required detail to ensure that peoples care and welfare needs were being met.

Staff were clear about the safeguarding procedures they should follow if they had any concerns that people were at risk of harm. .

The recruitment records that we looked at for three newly appointed staff showed that appropriate information had been obtained prior to them commencing their employment at Hill House. This ensured that the suitable checks had been carried out to assess the suitability of staff.

During an inspection on 15 March 2013, we had found that the provider was not compliant with the regulations relating to medicines. This inspection on 23 April 2013 showed that improvements had been made with the medication procedures.

We had received some information of concern in relation to the care and welfare of people, staffing levels and over all cleanliness of the home. During this inspection, we looked at the care plans and noted that some improvements were required in relation to the information recorded which would ensure people's needs were fully met. Whilst the cleanliness of the home was good, we noted that general maintenance, re-decoration and repair of the premises was required. Parts of the property needed attention, as they were looking worn and tired.

We found the staffing levels in the home were sufficient to meet people's needs and staff felt supported in their roles and received appropriate training.

During the inspection, we looked at the care files for three people who used the service. Whilst we noted that a number of people had lost weight during the last month, action had been appropriately taken to keep them safe and well.

We observed the care being provided and talked with staff who were very knowledgeable about the people who live at Hill House and were able to explain their needs. People we spoke with were all very happy with the care they received at Hill House and told us they were able to make choices.

We spoke with staff on duty who felt they were adequately staffed and felt well supported and appropriately equipped to do their job.

We looked at the medication administration storage, administration and disposal. We found that additional procedures need to be put in place to ensure people are not being placed at risk from medication omissions.

People who lived in the home and their relatives spoke positively about the care provided at the home. One person told us, "I'm very happy here, I don't need to tell you anything else." Relatives said that they, and their relative, were involved in the care planning process. The majority of responses from people, and their relatives, was positive about the staff team, with one relative describing them as, "Excellent". However, one person did tell us that not all staff responded positively when asked for something.

This was also raised as an issue during a residents meeting.

During our observations we noted situations in which the dignity of people was compromised. These all related to the absence of staff in the areas in which people were and so there was no-one to notice that someone required assistance. We had concerns about the staffing levels provided, particularly with regard to the number of people in the home who were living with dementia. Whilst the layout of the home provided people with a choice about where to spend their time it also meant that staff were not able to provide support in all areas.