Archived: Hillcrest House Care Home

At the last comprehensive inspection found breaches of the legislation. We took enforcement action, served warning notices and imposed conditions on the registration of this service. Following the inspection the provider developed a comprehensive action plan to meet the imposed condition of registration and to address the warning notices and other requirements where there were breaches of the regulations.

This inspection was unannounced and took place on the 22 February 2017. Hillcrest House can provide accommodation and personal care for up to 34 people living with dementia. At the time of our visit there were 11 people accommodated.

People told us they felt safe with the staff and we observed that people’s behaviours indicated they were happy for staff to approach them. The staff knew the aims of the safeguarding of vulnerable adults procedures. The staff knew the types of abuse and the responsibilities to report abuse where it was suspected.

Contingency plans and individuals evacuation procedures in the event of an emergency were in place. The contingency plans needed reviewing to ensure the contact details of staff currently employed were included. The plans detailed the contact details of the registered manager and contractors in the event of an emergency.

Mental Capacity Act (MCA) assessments for some people needed reviewing to ensure the best interest decisions were relevant to the specific decisions that was being made. We saw for example, that consent for photographs to be taken was gained from a relative without power of attorney. The MCA assessments lacked detail and action plans on the best interest decisions reached were not always in place.

Care plans were overall person centred and provided insight that people were living with dementia. However, action plans lacked detail on how staff were to meet the identified needs. We found information was duplicated and at times was not consistent and was contradictory. This may mean that staff were not provided with clear guidance on how to meet the needs of people. Activities were not taking place consistently to ensure people were able to pursue their interests.

The staffing levels met the basic needs of the people living at the service. Staff said that agency staff were used to maintain staffing levels. We were told that the same agency staff were used which improved consistency to people. Staff said staffing levels did not allow for staff to take people out in the community.

The provision of training had improved. This ensured that staff had the skills to meet people’s needs. There were opportunities for staff to undertake vocational qualifications. Staff were registered onto the Care Certificate. Staff told us there were opportunities for career progression within the organisation.

People’s dietary requirements were met. There were choices of meals and refreshments and in between meals there were snacks and refreshments available. We observed the lunchtime meal and we observed staff helping people to eat and drink and encouraging others to eat their meal.

Relatives told us where there were concerns these were raised with the unit manager. Where people were able they told us concerns were raised and addressed.

Quality assurance systems were in place. Feedback from relatives was being sought on the quality of the service. Social care professionals told us there had been improvements in the quality of the service. Members of staff told us the team worked well together and they were supported to meet the requirements of their role. An agency worker told us information was more accessible.

You can see what action we told the provider to take at the back of the full version of the report.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Hillcrest House on our website at www.cqc.org.uk

At this inspection we found the provider had taken action to address the issues highlighted in the warning notices. The provider had developed a comprehensive action plan to address the warning notices and other requirements in the inspection report where they were found to be in breach of regulations. We could not improve the existing inadequate rating because to do so requires a comprehensive inspection.

Hillcrest House can provide accommodation and personal care up to 34 people living with dementia. At the time of our visit there were 11 people accommodated

A registered manager was not in post. A unit manager was in post to provide day to day management presence. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law, as does the provider. 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 not able to tell us about their experiences of living at the home. We saw staff sitting with people and there was good interaction between them. People were assisted by the staff and their behaviour showed the intervention from staff was welcomed. We saw staff supporting people to make decisions for example choosing meals. All assistance offered by staff was accepted.

Members of staff said that they had refresher training to ensure people were safe. The staff we spoke with knew the types of abuse and the actions they most take for alleged abuse. For example they knew where there was physical abuse by one person towards another this had to be reported.

The whistleblowing procedure, including the contact details of agencies staff were able to raise their concerns with, was on display in the office. This included the organisation’s commitment to improve standards of care to people. Members of staff knew it was their duty to report any poor practice they may witness. They told us they would not hesitate to report alleged abuse to the line manager.

Risks had been assessed and associated risk assessments had been developed. Members of staff described the actions they must take reduce the risks to people. Risk assessments were in place for moving and handling, for people at risk of pressure damage and for people who may at times exhibit challenging behaviour.

We spoke with an external healthcare professional who said the service had improved since our previous inspection. Two staff said there had been improvements in the quality of care and were confident the improvements would be sustained.

The inspection took place on the 18, 19 and 23 May 2016 and was unannounced. It was carried out by two inspectors for each location with support from an inspection manager. On the third day two inspectors and CQC pharmacist inspector attended covering the whole site.

Hillcrest House can provide accommodation and personal care up to 34 people living with dementia. At the time of our visit there were 20 people accommodated

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law, as does the provider. 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. The registered manager was not present during our inspection. We found the service was not well led.

Permanent staff were aware of the procedure for safeguarding adults from abuse. They knew the signs of abuse and the expectations placed on them to report allegations of abuse. However, some staff were not confident to report abuse they may witness from other staff. Some staff were not able to convey without significant prompting a good understanding of the procedures for safeguarding adults from abuse.

Risk assessments were in place for moving and handling and for people at risk of weight loss and for choking. Members of staff knew the actions needed for them to minimise risk. Where people had sustained injuries such as bruising the reporting of these events was inconsistent. For example, staff had not followed the procedure of documenting the injury on a body map and taking photographs. Action plans were not developed on how to monitor the injury and an investigation was not conducted which meant the potential of abuse was not considered.

The relatives we spoke with said care was not consistent because there was a heavy reliance of agency staff. Staff told us they were often short staffed and on all the days of the inspection agency staff were used.

We saw during mealtimes that people were asked to select their preferred meal from the available choices. Permanent staff enabled people to make day to day decisions. However, some agency and relief staff showed a lack of knowledge about the people’s ability to make daily living decisions. This was due to staff not having sufficient information when they came on duty to meet people’s needs.

Mental Capacity Act 2005 (MCA) assessments were in place but were not always completed correctly about the decision makers. Staff had approached the Office of Guardianship about lasting power of attorney for some people and although they were informed none was in place, MCA forms were completed indicating one was in place. Staff had approached relatives without legal powers to make decisions on behalf of their family member for their consent to take photographs, medical care and for vaccines. MCA assessments for specific decision were completed for some people who resisted personal care. The best interest decision reached was not developed into a detailed care plan which gave staff guidance on how to deliver personal care using the least restrictive option when people did not accept personal care.

New staff said they had an induction when they started at the home but their description of the programme covered was inconsistent. For example one member of staff said their induction covered four shadow shifts and watching training videos before starting work unsupervised. Another member of staff said their induction had covered two shadow shifts. Staff said training was provided but they said the quality of the training was not always suitable for new less experienced staff. Staff did not all have regular one to one meetings with their line manager.

Permanent staff we observed had good interaction with people. We observed people approaching permanent staff for attention and we saw staff respond to reduce the person’s level of anxiety. However, agency staff didn’t always know people’s preferred first name and tasks were not always explained before they delivered care and treatment.

Care plans were not person centred and contradicted assessments of needs. They lacked detail on how staff were to meet people’s needs and lacked people’s preferences on how staff were to deliver their care. There was no central source of information for staff to update their knowledge of people’s needs as two systems were in use that included written notes and electronic hand held devices.

Relatives said the activities provided to their family member were good. The activities coordinator said there were one to one activities in the morning and group activities in the afternoon. Staff said when there was permanent staff on duty there was more time in the afternoon to participate in group activities. . They told us activities were limited at the weekends.

People had access to healthcare professionals for their ongoing health needs. However, care plans were not developed where needs assessments had identified oral, eye and chiropody needs. Relatives told us they were kept informed about important events as they occurred.

We found breaches of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

“The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

A team of four inspectors carried out the inspections across the three locations. On the day of our inspection of Hillcrest House there were 25 people living at the home. This location was inspected by two Adult Social Care Inspectors. We found that people living at Hillcrest House had varying degrees of dementia, which meant that many had limited ability to express their views about the home and their care and treatment.

The purpose of our inspection was to answer these key questions: 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?

We found that the care and support people received did not always meet their individual needs. This was because there was not always sufficient numbers of staff to look after people. We also found areas of the home that were not clean, which put people at risk.

Is the service effective?

The service was meeting the needs of some of the people living there, but was not as effective at providing support for those with more complex needs.

Is the service caring?

People who were able to voice an opinion were positive about the service. One person said ''I am very happy here, the carer's are kind and caring.'' Another stated ''We are all happy here, the staff are gorgeous.'' Another person said ''I am happy with my care.'' We spoke with a visitor who told us that they thought their relative was ''well cared for.''

Is the service responsive?

We found that the staff were referring people promptly for advice from healthcare professionals, which helped maintain their health and welfare.

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Is the service well-led?

The previous registered manager had recently left. Until a new manager took up the post management support was being provided by two senior managers. We found that the lack of a manager had impacted on the overall leadership in the home resulting in a reduced quality of service.

People told us they liked living in the home. One person said 'It's all right here.' Another person told us they could choose how they spent their daily life, saying 'Oh yes, I decide when I get up.' However another person told us 'not a lot happens here.' People we spoke with said the home met their needs. One person reported 'they look after you well,' another person said 'they're all very kind here.'

We observed how care was given to people on the two floors of the home. We saw all staff were consistently polite and supportive to people when they addressed them. They called people by their preferred names and when refreshments were served they offered people a choice of drinks. We saw staff taking time to make sure people understood what drinks they were offering. At lunchtime we observed staff were available to help people eat their meals. The staff gave people their full attention when they were supporting them with their meals.

People's needs were assessed and care plans were devised to show how staff were to meet people's needs. Where associated risks such as malnutrition and falls were identified, an assessment was undertaken to establish the level of risk. A care plan on how to lower the level of risk needed to be developed based on the assessment. This may mean staff were fully aware of the actions they needed to take to lower risk for people.

The staff we spoke with had received safeguarding adults training. They knew the types of abuse and the expectations on them to report suspicions of abuse. One member of staff told us 'the aim is to prevent abuse from happening.'

We saw staff had an understanding of people's needs and when behaviours were exhibited they responded in a gentle manner. We saw staff diverted people's attention when they became aggressive towards staff and other people. Staff encouraged people to drink fluids during the warm weather. We saw where people refused their meal staff offered another choice to encourage them to eat.

We spoke with a relative, a healthcare professional and a volunteer visiting the home during our visit. The relative told us they were happy with the care their relative received. We were told the staff kept them informed of important events such as GP visits. The healthcare professional told us staff acted on their advice by addressing the feedback in the care people were given. The volunteer said staff were less responsive to their comments and suggestions.

We found staff were using restraint to force people to accept personal care. Staff had not been given adequate support to ensure restraint was used as a last resort and when used guidance to be followed to ensure restraint was carried out safely. At times people had physically 'hit' other people living in the home. The managers of the home were aware of these events but had not made referrals to the local authority for safeguarding advice and assistance.

The people we asked about the meals served made the following comments 'I don't eat it if I don't like it,' 'I go without it if you don't like it', 'excellent', 'good enough for me.'

We saw members of staff offering people choices of dessert and we saw staff encourage people to eat. We heard staff say 'try to eat', and ask people if they enjoyed their meal. We saw staff calmly diffuse potentially aggressive situations.

Two visitors at the home told us the care provided by the staff was good. We were told activities were organised, for example, arts and crafts and outings. Both visitors said they were able to approach the staff if they were not happy with the care provided.