Archived: Hillcrest Care Home

This inspection took place on 2 October 2018 and was unannounced. This meant that the provider and staff did not know that we would be visiting. We carried out two further announced visits on 10 and 25 October 2018 to complete the inspection.

We last inspected the service in August 2017, where we found two breaches of the regulations. These related to meeting nutritional and hydration needs and good governance. We rated the service as requires improvement.

Following our inspection, the provider sent us an action plan which stated what actions they were going to take to meet the regulations.

At this inspection, we found that the provider had taken action in relation to meeting nutritional and hydration needs and good governance.

There was a registered manager in post. She had become registered with CQC following our previous 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 and associated Regulations about how the service is run.

The service was going through a period of change. The registered manager told us that she was trying to ensure the smooth running of the service amidst the changes which were happening to make sure people experienced the best possible outcomes at Hillcrest Care Home.

Whilst staff carried out their duties in a calm unhurried manner in the dementia care unit; staff in the nursing unit appeared to be constantly busy, moving from task to task, leaving little time to communicate on a social level. Some staff told us that team work could be improved between the units and also between the different shifts. We have made a recommendation about staff deployment.

There were systems and procedures to help protect people from the risk of abuse. People and relatives told us people were safe. Medicines were managed safely.

There was a training programme in place. Staff said however, that most of the training was online. They explained that it was sometime difficult to get online and said that they did not find e-learning as interesting or engaging as face to face training. We have made a recommendation about this.

There was a supervision and appraisal system in place. Supervision and appraisals had not been carried out as regularly as planned because several nurses and a senior care worker who supported the registered manager undertake these with staff, had recently left. There was a plan in place to address this shortfall.

People were supported to eat and drink enough to maintain a balanced diet. Nutritional care plans were individualised and included information about where the person liked to have their meal together with their likes and dislikes. Special recommendations from health care professionals were also recorded.

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.

We observed positive interactions between staff and people who lived at the service. Staff talked about caring for people like members of their family.

There was an activities programme in place. An activities coordinator was employed to meet people’s social needs. The registered manager said they were reviewing the home’s activities provision to ensure that activities were person centred and promoted people’s maximum involvement.

There was a complaints procedure in place. Records were available to document what actions had been taken to resolve the complaints.

Audits and checks were carried out to monitor the quality and safety of the service. Action was taken if shortfalls were identified. An overarching action plan was in place which was linked to CQC’s five key questions.

This is the fourth time the service has been rated requires improvement.

We last carried out an inspection in July 2016, where we found two breaches of the regulations. These related to meeting nutritional and hydration needs and premises and equipment. We rated the service as requires improvement in three key questions; is the service Safe? Effective? and Well led? The service had an overall rating of requires improvement.

Following our inspection, the provider sent us an action plan which stated what actions they were going to take to meet the regulations.

At this inspection, we found that the provider had taken action to improve the safety of the premises. However, we found continuing shortfalls with meeting nutritional and hydration needs and identified a breach in good governance.

Hillcrest Care Home provides care and accommodation for up to 52 people, some of whom are living with dementia. The home was divided into two floors. People with a dementia related condition lived in ‘Tree Tops’ which was located on the ground floor. People with nursing and general care needs lived on the first floor. There were 43 people living at the home at the time of the inspection.

Since 2013, there had been three managers. Two of whom had been registered with CQC. The present manager was in the process of becoming 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 and associated Regulations about how the service is run.

The registered provider had changed their trading name from Dolphin Property Company Limited to Mariposa Care Limited in February 2017. This was not a change of registered provider.

Checks and tests had been undertaken to ensure that the premises were safe. The home was clean and staff had access to personal protective clothing such as gloves and aprons.

There were safeguarding policies and procedures in place. The local authority safeguarding team informed us there were no organisational safeguarding concerns regarding the service. We found shortfalls with the management of medicines on the nursing floor.

We received mixed feedback from people and relatives about whether there were sufficient staff on duty. Most staff told us there were insufficient staff deployed on the nursing floor. Staff from this floor explained that sometimes the two different floors did not always work together as a team. Some were reluctant to help on another floor during busier times. We have made a recommendation that the provider reviews its staffing system to ensure staff are deployed flexibly across the home to meet people’s needs.

We checked how people’s nutritional needs were met. We found that people’s meals did not always correspond with guidelines issued by the speech and language therapist.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. MCA is a law that protects and supports people who do not have ability to make their own decisions and to ensure decisions are made in their 'best interests'. It also ensures unlawful restrictions are not placed on people in care homes and hospitals. We found that staff were acting in people’s best interests; however, records did not always evidence how the Mental Capacity Act 2005 was followed.

There was a supervision and appraisal system in place. Some staff told us that supervision meetings had not been carried out as regularly as planned. Staff had completed training in safe working practices. One staff member who had recently commenced employment at the home had not undertaken training in certain clinical skills.

We observed positive interactions between staff and people who lived at the service. Staff promoted people's privacy and dignity.

Arrangements for social activities met people’s individual needs. There was a complaints procedure in place.

We identified shortfalls in the maintenance of records relating to people and the management of the service. The provider’s own governance system had highlighted omissions relating to record keeping.

Since 2013, we found the provider was breaching one or more regulations at five of our seven inspections. In July 2016, we rated the service as requires improvement. At this inspection, we found that improvements had not been fully implemented .This meant that compliance with the regulations was not sustained and consistency of good practice was not demonstrated.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to meeting nutritional and hydration needs and good governance. You can see what action we told the provider to take at the back of the full version of the report.

We last carried out an inspection in September 2015, where we found a continuing breach relating to the condition and safety of the premises. We issued a warning notice and told the provider that they must take action to improve. We also identified breaches in regulations 11 and 17, relating to the need for consent and good governance.

At this inspection we found that action had been taken in these areas, however further action was required with regards to the premises.

Prior to our inspection in July 2016 we received an anonymous concern about the environment, infection control and staffing levels at the service. We took this information into account when we were planning our inspection.

Hillcrest Care Home provides care to a maximum of 52 older people, including those with a dementia related condition. There were 38 people living at the home at the time of the inspection

There had been a change in the provider’s management structure. A new management company called Careport had taken over the management of the service on 11 July 2016. Careport manages care homes across the UK on behalf of their owners.

We spent time looking around the service and saw that a full refurbishment of the home had taken place. Careful consideration had been given to ensure that the environment met the needs of people with a dementia related condition. Previously, the dementia care unit and nursing units were spread across two floors. Now, each unit was located on a specific floor; the dementia care unit was located on the ground floor and the nursing unit was on the first floor. We found however, that the nurse call and fire alarm system did not correspond to the new layout of the home. This meant there was a risk that people may not receive care in a timely manner and the location of a fire could not be identified by staff. The manager had put in place contingency arrangements in relation to these two issues. She told us that these were being addressed the week after our inspection. We passed our concerns to the local authority and fire safety officer. Following our inspection, the manager confirmed that the fire alarm and nurse call systems were now fully operational.

Some of the front covers on the radiators were broken and hanging off which was a health and safety risk. We checked equipment at the service and found that equipment for certain clinical tasks was not always available.

We checked how people’s nutritional needs were met. Most people and relatives said that meals could be improved at the home which was confirmed by staff. We observed the lunch and tea time periods and saw that although staff were attentive to people’s needs, meals did not always look appetising and we observed that one meal which had been prepared for those who required a blended diet was not suitable because it contained lumps of potato. We examined the menus and noticed that there was no choice for those who required a soft or blended diet.

Following our inspection, the manager told us that the menus had been changed and positive feedback had been received about the improvement in the meals. In addition, they were receiving support from the local NHS trust’s dietetic team.

There was a registered manager in post. She became registered with the Commission in May 2016. 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. Most people, relatives and staff were positive about the manager. One staff member said, “I find her really supportive.” Several staff and a relative told us that they did not like her management style.

We received mixed comments about whether there were sufficient staff on duty. Most people told us that staff met their needs in a timely manner. However, two people and several relatives said that more would be appreciated. Most staff said that more staff were required. A staffing tool linked to the dependency of people who lived at the home had not been carried out at the time of the inspection to ensure that staffing levels met the needs of people who lived there. Following our inspection, the manager told us that she was now completing a staffing tool which showed that they were staffing the home above the recommended levels. She also said she had deployed an extra care worker on the nursing unit on most days.

We checked recruitment procedures at the service. Staff told us and records confirmed that checks were carried out before they started work at the service.

There were safeguarding procedures in place. Staff knew what action to take if abuse was suspected. We spoke with a local authority safeguarding officer who told us that there were no organisational safeguarding concerns regarding the service. People’s medicines were managed safely.

The manager provided us with information which showed that staff had completed training in safe working practices and to meet the specific needs of people who lived at the service, such as dementia care training.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. MCA is a law that protects and supports people who do not have ability to make their own decisions and to ensure decisions are made in their ‘best interests’. It also ensures unlawful restrictions are not placed on people in care homes and hospitals.” We found that the provider had taken action to improve in this area and the manager had now submitted DoLS applications to the local authority to authorise in line with legal requirements. We found that further improvements were required however, to ensure there was documentary evidence to demonstrate how the requirements of the MCA were met.

There was a complaints procedure in place. Feedback systems were in place to obtain people’s views. Meetings and surveys were carried out. The manager informed us that they had not received the analysis of the 2015 survey feedback from the provider.

We identified shortfalls during our inspection. These related to the premises, the assessment of staffing levels, meeting people’s nutritional needs and evidencing of the MCA. Although audits had highlighted some of these issues such as concerns regarding the fire alarm and nurse call systems, action was not always taken in a timely action to address these.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to the premises and equipment and meeting nutritional and hydration needs. You can see what action we told the provider to take at the back of the full version of the report.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

Below is a summary of what we found:

Is the service safe?

We spoke with three relatives and seven people to find out their opinions of Hillcrest. We also spoke with two clinicians in challenging behaviour, a local authority care manager, safeguarding officer, contracts and commissioning officer, a GP, a community matron for nursing homes, a staff nurse from the local hospital and a member of the district nursing team to find out their views.

Systems were in place to make sure that lessons were learnt from events such as accidents and incidents and complaints and concerns. This reduced the risk to people and helped the service continually improve.

However, we had concerns about the condition of the premises. We found that some of the paintwork was damaged in the corridors and most of the carpeted areas in the corridors in both units had black tape across the joins to prevent the carpet from lifting. Water temperatures were not always kept within recommended limits and the electrical safety installations test was out of date. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. The manager informed us that no one was currently subject to Deprivation of Liberty Safeguards (DoLS). DoLS are part of the Mental Capacity Act 2005. They aim to make sure that people are looked after in a way that does not inappropriately restrict their freedom. The manager told us that she was aware of the recent Supreme Court judgement regarding what constituted a deprivation of liberty. She explained that she was in the process of considering what implications this ruling had on people who lived at Hillcrest.

Is the service effective?

People were happy with the care that was delivered. They told us that their needs were met. One person commented, "The care is second to none." It was clear from our observations, and through speaking with staff that they had a good understanding of people's care and support needs.

Is the service caring?

We saw that care workers showed patience and gave encouragement when supporting people. Health and social care professionals informed us that they had no concerns about people's care and welfare. There was a cheerful atmosphere; many staff had worked there for a considerable period of time. This experience contributed to the efficiency and skill with which staff carried out their duties.

We read the comments in a card sent by a relative to the home. This stated, 'The care and kindness that everyone showed was absolutely wonderful and I thank you all from the bottom of my heart.' We also checked questionnaires which had been completed by people and their relatives about the care and treatment which staff provided. One relative had written, 'I have been particularly impressed by the continuity of care. My mother has had more or less the same people looking after her since she came to Hillcrest over five years ago. She has been able to build up an excellent relationship with them.'

Is the service responsive?

People's needs had been assessed before they visited the service. People had access to activities that were important to them and had been supported to maintain relationships with their friends and relatives. On the day of our inspection, a trip to Kielder had been organised.

We saw that referrals were made to the GP, district nursing team, challenging behaviour team, podiatrist, dentist and other health and social care workers. We noted that the advice of these health and social care professionals was incorporated into people's care plans which helped ensure staff were aware of this information. One relative with whom we spoke, informed us that she felt that staff were responsive to people's needs. She explained that staff had liaised with the challenging behaviour team for advice and support in relation to her father's care.

The home had a complaints policy and people and relatives told us that they felt able to raise any concerns they had. The manager explained that no formal complaints had been made in 2014.

Is the service well-led?

A manager was in place who was registered with the Care Quality Commission. People, relatives and health and social care professionals spoke positively about her and her leadership. One person told us, 'You couldn't get a better manager.'

The service had a quality assurance system and records seen by us showed that identified shortfalls were generally addressed promptly.

Staff told us they were clear about their roles and responsibilities. They informed us that regular meetings were held. This was confirmed by minutes of meetings. Staff morale at the home was good and staff spoke positively about working there and the support the manager gave them.

There was a new manager in post. She has applied to the Care Quality Commission to become a registered manager on our register.

We spoke with fifteen people and five relatives to find out their opinions of the service. One relative said, “There’s genuine care.”

We concluded that if people did not have the capacity to consent, the provider acted in accordance with legal requirements.

We found that people’s care and treatment was planned and delivered in line with their individual care plan.

We spoke with a number of health and social care professionals to find out their opinion of the service. These included a GP, a member of the district nursing team, a challenging behaviour clinician, a dietitian, a continence advisor, an enabler, an optometrist and optical assistant, a speech and language therapist, and a member of the local authority review team. We concluded that people’s health, safety and welfare was protected because the provider worked in co-operation with others.

People told us that the home was always clean. However we found that effective systems were not fully in place to reduce the risk and spread of infection.

We concluded that people, their representatives and staff were asked for their views about their care and these comments were acted on.