Greenhill Residential Care Home

Greenhill Residential Care Home (Greenhill hereafter) is a residential care home providing personal care to up to 36 people. The service provides support to people aged 65 and over including people with physical health needs and people living with dementia. At the time of our inspection there were 20 people using the service. Accommodation is over two floors and each person has a spacious ‘flat’ which consists of a small hallway, a bathroom, and a bedroom; most of which have a kitchenette area. There is a large communal lounge and dining room, and two further quieter lounge areas. There is a safe and enclosed central courtyard garden.

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

People told us they were happy living at Greenhill. Peoples’ risks were assessed and regularly reviewed. Peoples’ care plans gave staff clear direction of how to support people to manage risk in a safe and person centred way. One person’s family member told us that a “huge amount of work” had been done around their loved ones choking risk, and felt that staff had done a, “Really, really good job.”

Staff were recruited safely and there were enough staff to meet peoples’ needs. Call bell response times were checked daily to ensure people did not have to wait too long for assistance. We observed staff to be calm and unhurried. Improvements had been made to infection prevention and control and the service was adhering to current UK Government guidance relating to the management of Covid-19. The home was clean, tidy and free of offensive odours.

People received their medicines safely and staff administering medicines had been trained and assessed as competent to do so. Systems were in place to ensure safeguarding concerns were identified and reported appropriately. People, and their families, told us they felt safe at Greenhill. People were supported to see visitors in line with current UK Government guidance. Each person had an ‘essential caregiver’ who were able to visit daily. Risk assessments relating to isolation had been completed. These considered what impact the restrictions of visitors, including during an outbreak, might have on the persons physical and mental well being, and detailed how to mitigate these risks. Peoples’ families told us they were supported to visit in a safe way.

New staff completed a structured induction, including shadowing experienced staff for as long as necessary, before working independently. A training programme had been implemented and the training matrix demonstrated good progress had been made since our last inspection. Systems had been put in place to ensure staff received regular supervision, to discuss their role and ongoing training needs.

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.

Improvements had been made to the mealtime experience and people were now able to choose from a range of options, with food and drink available 24 hours a day. People told us they enjoyed the food. One person said, “If you go hungry here it’s your own fault.” One person’s family member told us, “Mum used to complain about the food all the time, but she doesn’t now.”

Peoples’ needs were assessed, and care was delivered in line with current guidance and the law. People were supported to access healthcare services and staff worked with health professionals to ensure people’s needs were well met. One visiting health professional told us that Greenhill had “changed immeasurably”, and that they were “confident that instructions would be followed, and that they would be contacted at an appropriate time.” Peoples’ families told us staff acted quickly when needs were identified. Peoples’ needs were considered when making changes to the environment. For example, new menu holders had been ordered to make it easier for people to see, and a new drinks trolley had been provided to enhance the mealtime experience. Changes were made to peoples’ individual rooms where necessary.

People were well supported by staff who were caring, respectful and kind. People were well presented and were having their personal care needs met, including, where required, regular support with oral hygiene. People and their families were fully involved in making decisions about their care. Peoples’ emotional needs were well met. People were not left unattended for long periods of time and staff spent time talking with people and supporting them to engage in an activity. Peoples’ families told us staff were kind and caring. One said, “Mum is so happy.” Another said staff, ‘Call her darling and she loves it.’ A third family member told us their loved one, ‘Gets very good care, can’t fault them.’ Another person’s family member told us how they were moved to tears when they received a valentine rose that staff had supported their loved one to make for them. They said it, ‘Meant more to me than I can say. The staff are super, they really, really care.’

Peoples’ care plans contained clear information to enable staff to meet their needs; they contained information about people’s daily routines, how they liked to spend their time and what staff could do to support them. One person’s family member told us, ‘The quality of care now is good. The staff have changed, their attitude has changed, they are more interested in people.’ Improvements had been made to the way activities staff worked and the monitoring of social interactions. One staff member told us how they spend time with people who choose to stay in their flats and provide individualised activities such as large print wordsearches. Records demonstrated people were having social interaction on a daily basis and staff confirmed they had more time to spend with people.

People were well supported at the end of their life. People and their family members were involved in creating care plans which reflected their wishes as they neared the end of their life. One relative said the care their loved one received at the end of their life was “Excellent, ten out of ten.”

Systems had been implemented to ensure the quality of the service was monitored and regulatory requirements were met. This included daily, weekly and monthly monitoring and a range of audits across the service which had been regularly completed. The provider had strengthened reporting systems and received structured and detailed reports from the registered manager on a regular basis. They had also introduced a new quality monitoring role. A number of new staff had been recruited into senior management roles, including the registered manager. Staff, people and their families all spoke highly of the new management team, and their confidence in them. The culture of the service was positive, and person centred. We asked staff how they felt about the changes within the home, comments included, “Staff morale is really good.” “It’s poles apart! I can see such a big difference.” “they’ve done an amazing job, I’m really impressed, having new staff with that bit of ‘oomph’ has made a real difference.” Peoples’ families also reflected on the positive changes. One said, “It’s been amazing since the changes.” Another family member told us the home has a “lovely feeling.”

Peoples’ families told us they were always informed of any changes in their loved ones’ health or of any incidents. The management team had worked with the Local Authority since our last inspection to implement the changes needed to ensure they met their regulatory requirements. Health professionals we spoke with gave positive feedback and recognised that the care provided at Greenhill had improved since our last inspection. One visiting health professional told us the whole team had commented upon the improvements. The management team sought continuous feedback from people, their families and professionals. ‘Feedback Friday’ gave a weekly opportunity for people to be involved in the development of the service. Staff told us they felt valued and listened to.

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

Rating at last inspection and update

The last rating for this service was inadequate (published 13 October 2021.) The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

At our last inspection we recommended that records relating to ‘as required’ (PRN) medicines be reviewed, so staff could ascertain when these medicines should be offered. At this inspection we found that records had been reviewed, and there were clear protocols in place for each PRN medicine prescribed, including detail as to whether the person would be able to communicate a need for it or if staff would need to anticipate this. We also recommended the provider consider ways about giving people more choices about what they were able to eat and drink. The provider had made improvements.

This service has been in Special Measures since 13 October 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last 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 COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from inadequate to good based on the findings of this

Greenhill Residential Care Home is a residential care home providing personal care to 33 people aged 65 and over at the time of the inspection. The service can support up to 36 people. Accommodation is over two floors and each person has a spacious ‘flat’ which consists of a small hallway, a bathroom and a bedroom with a kitchenette area. There is a large lounge and dining area on the ground floor and a second quieter communal room.

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

People were not protected from the spread of infection. Staff were not using personal protective equipment (PPE) in line with either UK Government guidance or the providers own policies. On the first day of our inspection we observed numerous members of staff either not wearing a mask at all, wearing one incorrectly or wearing the wrong type of mask. No action had been taken to encourage good infection control practice around the building and staff had not completed any Covid-19 specific training. Some improvements had been made by day two of our inspection.

People at risk of choking were not always supported safely or in line with the advice of external professionals. There were not enough staff to meet people’s needs and a high level of staff sickness exacerbated this. Peoples medicines were generally managed well, and risk to people and risks associated with equipment and premises were regularly reviewed. We recommended that records relating to PRN medicines be reviewed and sufficient information be recorded to enable staff to identify when it is appropriate to use them. Staff told us they knew how to recognise and report safeguarding concerns.

New staff did not receive a thorough induction and most staff had not completed training required to ensure they had the required knowledge and skills. One staff member told us “I can’t remember the last time we had any training.” Very few staff had completed first aid training and there were often no first aid or fire trained staff on duty.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the systems in the service did not support this practice. There was confusion and misunderstanding about their responsibilities under the Mental Capacity Act; applications to deprive four people of their liberty had been made without first assessing their capacity to make the decision for themselves.

Advice from healthcare professionals was not always sought in a timely way. People were not encouraged to be involved in the design and decoration of the service; however, some improvements had been made including décor to make peoples flat doors look like the front door to a house, ‘cloud’ feature lights and redecoration.

People were not always treated with dignity or well supported. People were not being regularly assisted with oral hygiene and staff confirmed to us that this was an ongoing problem. One senior member of staff told us that care was “very basic.” Staff used some institutionalised language and people were drinking out of plastic cups with no rational as to why. Staff were working hard to meet people’s needs as best they could, and we observed some kind interactions. People seemed comfortable when interacting with staff. One person told us “the staff are wonderful, they really are.”

People did not always have care plans in place. Since the last inspection, an electronic care planning system had been introduced. We found two people had electronic care plans in place with very minimal information, and a further six people had no care plans at all. This meant staff had little or no guidance as to how to meet their needs or what their personal preferences were. People who had lived at the service for more than 12 months had paper care plans in place, and whilst they were of good quality, staff told us they did not have time to read them.

At our last inspection we recommended that there be more robust arrangements for meeting people’s leisure and social needs on a more regular basis to ensure everyone’s particular needs were known and met. Improvements had not been made. We observed people in the communal lounge engaging with and enjoying an activity, however no meaningful activity was provided for people remaining in their rooms. Records showed long periods of time where some people had no social interaction.

At our last inspection we recommended that the provider ensured their oversight and governance was more robust to ensure the Registered Manager and staff were more supported and clearer about their roles. Improvements had not been made. The Registered Manager was not clear about their responsibility to follow UK Government guidance in relation to infection control and the Covid-19 pandemic. They had not implemented the guidance, nor followed the providers own policies. The provider had failed to make any checks. Whilst there were quality assurance systems in place, they did not always identify where improvements were needed, or where they did identify it action was not always taken to resolve it.

Staff told us the registered manager was supportive and worked with them to provide care when staffing levels were low, however, it was clear that they did not feel well supported by the provider. Staff told us they were upset to have not had any thanks from the provider throughout the Covid-19 outbreak. The Registered Manager worked in isolation, had not engaged in any local support networks and without guidance from the provider had found it difficult to keep up to date with current guidance and best practice.

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

Rating at last inspection and update

The last rating for this service was Requires Improvement (published 14 June 2018). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

We undertook this focussed inspection to check they had followed their action plan and to confirm they now met legal requirements.

On day one of our inspection we identified significant concerns in relation to the management of infection control, the use of personal protective equipment (PPE) and how risks for people with impaired swallow were managed. Because of these concerns we expanded the scope of our inspection to a full comprehensive.

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.

The overall rating for the service has changed from Requires Improvement to Inadequate. This is based on the findings at this inspection.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to: safe care and treatment; person centred care; dignity and respect; need for consent; staffing and good governance at this inspection.

We also made two recommendations to improve practice in relation to the administration of 'as required' medicines and supporting people to make choices at mealtimes.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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.

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.

Greenhill Residential Care Home is a care home that accommodates 36 people in a purpose built residential home for the elderly. At the time of our inspection 31 people were using the service, including two people currently in hospital. Some people using the service were living with dementia or had physical support needs. Support is provided on two floors. There are various communal areas, including lounges and a quiet room that people can access. The home also has an enclosed garden in a central courtyard.

People’s experience of using this service:

The new provider and management team had worked hard to address issues at the home since they bought the service in 2018. At the time of the purchase the service had been rated as inadequate in all domains. The new provider had ensured there were audits in place which were effective in continually developing the quality of the care that was provided to people. However, although some areas such as training, induction and supervision had been identified as areas for improvement these had not been fully addressed in a timely way. People and staff were happy with the way the service was led and the registered manager made themselves available to people. However, more robust governance and availability from the provider would ensure the management team and staff felt more supported especially if their job description was unclear.

Although the care plans reflected people’s current needs, this information was not always used consistently by staff to ensure they were delivering person centred care. Some staff said they mainly relied on verbal handovers and communication. Most of the care plans were still in the previous provider’s format and transfer to QH Greenhill Limited documentation was ongoing but slow.

Arrangements for activity and leisure provision were in place and offered meaningful and appropriate activities. However, in practice not all people were included or the time some people spent engaged in activities was limited. The registered manager and provider were aware of all these issues and were now addressing them as a priority.

Staff knew how to keep people safe from harm and they received their medicines as prescribed. The provider had a robust recruitment process in place and there were enough staff on duty to meet people's needs. Staff followed infection control guidance and had access to personal protective equipment. The environment was friendly, warm, and clean. Accidents and incidents were recorded, and appropriate action taken.

Staff referred to healthcare professionals when required. People had a choice of food and their nutritional needs were met. The provider was working in line with the principles of the Mental Capacity Act 2005 and people's consent was obtained before care and support was delivered.

Staff were caring. The registered manager and staff were seen to deliver care and interact with people in a kind and caring way. All the people and relatives we spoke to were complimentary about the service. Comments included, “I would like to thank everyone who cared for my mother in the last few years of her life. All the staff were kind and respectful towards my mother at a time when she was in so much pain, and were careful not to make her distress worse” and “Just a note to say how much I appreciated all the support everyone gave me at the end of [person’s name’s] days. Although it was a sad time for me, having you all with me helped so much. Thank you.”

There was a positive, caring culture and staff were patient, kind and empathetic. A core group of staff had stayed with the service during the transfer to the new provider and clearly cared about the people living at Greenhill. They were positive about the improvements and staff culture saying, “It is definitely better here. 100% better. The registered manager and deputy manager have been so supportive. Much better staffing levels and agency use is reducing. The care is so much better because we have time to help people" and “I feel things have definitely improved here. The registered manager is really trying to get training up to date. I feel supported in my role, it’s easier now there are more seniors, lightens the load.”

People's privacy, dignity and independence were respected by staff. Support was generally individualised, with most staff knowing people well. Regular feedback was encouraged from people and their relatives.

The service ensured people received dignified and respectful end of life care which met their personal needs and preferences. The provider had a complaint process which people and their relatives were aware of to share any concerns and these were managed well.

Why we inspected: This inspection was planned as the location was newly registered under a new provider. The new provider took over the registration of the service in May 2018.

Rating at the last inspection: This was the location’s first inspection since registering with the Care Quality Commission (CQC).

Follow up: We identified one breach of the Health and Social Care Act 2008 relating to training, supervision and appraisal and made three recommendations. An action plan will be requested to ensure improvements are made. We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. 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