About the service:

Hill House is a care home that was providing nursing and personal care personal to people. 28 people were living in the home at the time of the inspection.

People’s experience of using this service:

¿ The monitoring of medicine management needs further improvement. Guidance was not always available for staff to give people their medicines safely.

¿ Some people at times could display anxiety through verbal or physical behaviours. We found that the documentation around this to support staff was not always appropriate. There was no specific behaviour care plan or risk assessment in place.

¿ People told us they felt safe living at the home. Staff had the knowledge and confidence to identify safeguarding concerns and act on them to protect people.

¿ The meal experience for people was positive. Mealtimes were sociable and interactive and provided by attentive staff. People were informed of the choices and if they wanted an alternative this was provided.

¿ We saw that where a person lacked capacity an assessment had been completed. At times the assessments were generic and more information was needed around how information was given to a person to aid their decision making.

¿ People received care and support from staff who had got to know them well. Staff knew, understood and responded to each person’s needs in a caring and compassionate way.

¿ The provider had a system in place to monitor the quality of the service people received. However, some of the audits in place had not identified all of the issues that we found during this inspection.

¿ Services are required by law to send us statutory notifications about incidents and events that have occurred at the service and which may need further investigation. At this inspection we found the provider had failed to submit two notifiable events.

More information is in Detailed Findings below.

Rating at last inspection:

Requires Improvement (report published 21 June 2018).

Why we inspected:

This was a planned inspection based on the rating at the last inspection.

Follow up:

We have told the provider they must take action to improve the service. We have made two recommendations around medicines following this inspection. We will continue to monitor the service and complete a further inspection to assess whether the improvements have been made.

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. The service can provide accommodation and nursing care for up to 35 people at this location. The service had two buildings at this location from which care was delivered, however only the new building was occupied at this time. At this inspection there were 23 people living in the home, however one person was receiving a respite service. The inspection took place on 16 and 17 May 2018 and was unannounced.

This inspection was a planned inspection to follow up on the concerns found at our last inspection in October 2017. At the inspection in October 2017 we found seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. A recommendation was also made in response to medicines management in the service. The service received an overall rating of 'Inadequate' and was placed into 'Special measures' by CQC. The purpose of special measures is to ensure that providers found to be providing inadequate care significantly improve. The concerns we found included ineffective assessment of risks to people, monitoring records not correctly completed and insufficient staff to respond to people’s needs.

Due to the number of concerns we wrote and met with the provider, to request an action plan to immediately address these shortfalls and keep people safe. The provider responded to this letter within the timeframe and has continued to send monthly improvement plans. The provider also placed a voluntary embargo on the service, which meant they would not increase the number of people they supported until they had made the necessary improvements.

At this inspection we found that improvements had been made and the service had met five of the previous breaches identified and part of another breach. The service remained in breach of two Regulations. The service is no longer rated as Inadequate and therefore will be taken out of ‘Special measures’. This service will continue to be monitored and re-inspected shortly, to ensure the improvements continue and are sustained.

The previous registered manager had left the service shortly after the last inspection. A new registered manager was now in post supported by a new management team. A consultant had also been working with the service since the last inspection to identify shortfalls and support the necessary improvements. 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. The registered manager, management team and owners were both present and available throughout our inspection.

Where there were risks to people these had been identified and a risk assessment put in place. However we saw that the information on some risk assessments was sometimes limited. A new format was in place for recording accidents and incidents; however these were not completed appropriately in order to be an effective investigation record.

People were supported by a sufficient number of staff who were currently supporting people in one building only. Staff felt that care was un-rushed and that they had time to spend talking with people.

At this inspection although we saw a few further improvements were needed, action had been taken to improve the management of medicines. People and relatives told us they were happy with the arrangements for staff managing medicines.

The service had not made the necessary improvements and remained in breach of the Regulation around consent. This is the second consecutive time the service has been in breach of this Regulatio

Hill House Care Home provides accommodation and nursing care for up to 35 people. At the time of our inspection there were 19 people living at the home and three people staying on temporary respite care.

We inspected Hill House Care Home on 18 and 19 October 2017, this inspection was unannounced. The service was previously inspected in October 2015 and received an overall rating of Good. In February 2017 the service increased the number of people they could support to 35 with the addition of a new contemporary building. The old building and the new are joined by a covered outside walkway. In addition the provider added the provision of nursing care to their registration. Work was underway to extend the new building which would provide a further 25 rooms. This will increase the service to 60 beds in total.

During this inspection we found seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. A recommendation was also made in response to medicines management in the service. You can see what action we told the provider to take at the back of the full version of the report.

The overall rating for this service is 'Inadequate'. This means that it has been placed into 'Special measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Due to the number of concerns we wrote to the provider requesting an action plan to immediately address these shortfalls and keep people safe. The provider responded to this letter within the timeframe and we are currently considering what action to take.

There was a registered manager in post when we inspected the service. 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.

Risks in the service had not been well managed. Risk assessments were not always updated to review safety measures. People did not always receive the care and support they needed to prevent risks in areas such as mobility and pressure area care. Fire records to make sure that people could be evacuated safely were not up to date and staff were not adequately trained to make sure they could respond effectively in the event of a fire.

Staffing levels in the home were not sufficient when taking into account the layout between two separate buildings and the number of floors. The registered manager did not calculate the staffing levels in accordance with people’s needs, but instead was told the numbers they could use by senior management. Staff had previously raised concerns around shortages, which had not been investigated.

Safe recruitment practices had not always been followed or the necessary checks completed to ensure new employees were safe to work with vulnerable adults.

Staff were not trained sufficiently in all areas to make sure they were effective in their roles. There was a lack of regular supervision to support staff to undertake their roles safely.

People’s choices were not always promoted or respected. This included decisions on where people preferred to spend their time and around meal choices.

We found concerns around staff understanding and recording of people’s mental ca

We visited Hill House on the 5 September 2013 in response to information of concern. During our visit we spoke with five people who lived in the home, three care workers, the housekeeper and the assistant chef. We also spoke with the manager and the provider.

We found that people were well looked after and people told us this. One person said "This is such a lovely place and the staff are wonderful". Another person invited us to see the vegetables they had grown in the vegetable patch and were rightly proud of. We observed that people moved around the home freely, that staff were attentive and respectful.

In response to the concerns raised, we asked the manager if they had received any complaints which related to these concerns. They told us they had not. We saw that the home had effective systems in place for responding to complaints and listening to informal issues or concerns. The manager showed us a book where staff, visitors and others could record things they wanted to be addressed.

We found that that the concerns raised were unsubstantiated as there were acceptable explanations and appropriate actions had been taken. Unfortunately, the provider had not had the opportunity to respond to the concerns directly. Had this been the case then the manager would had been able to provide clarification and evidence of the actions taken.

Hill House was a large country house which was well maintained. The accommodation was set over two floors with bedrooms on each floor. On the ground floor was a large dining room and a smaller library/lounge room. The home was clean, warm and smelt fresh.

People were supported by staff to make their own decisions. Throughout our visit we observed that staff sought consent from people and supported them to make their own decisions. For example, in what they wanted to eat and drink or in taking part in the craft activity. We spoke with one person who told us, "If I can't decide something staff always come back later when I've made my mind up".

We saw that people were well cared for and were involved in their care planning. One person said, "I came in here for a break and it's been wonderful". A care worker explained that each person had a personal care plan which took into account their individual needs and preferences.

The chef said that people were asked what they would like to eat and made suggestions for the menu. They said that most people liked wholesome traditional food. All of the people we spoke with said how lovely the food was. We observed that lunch was a sociable affair and people really seemed to enjoy their food.

We found that appropriate checks were undertaken before staff began work and there were effective recruitment and selection processes in place. Information was available to people and their families on how to make a complaint.

During our visit we spoke with 12 people who lived at Hill House Residential home. One person told us they had lived there for a long time. They said they were, “very happy, the staff were kind and they were treated respectfully”. Throughout our visit we noted that all staff referred to people by their names and were respectful and friendly.

We saw that the bedrooms in the home varied in size and outlook. People had personalised their rooms with their own furniture, pictures and possessions, which gave the rooms an individual and homely feel. We saw that some people had their own telephone. One person said, “it’s a lovely place and staff are very good and I love my room, look at that view”.

People told us they felt safe within the home and with the staff. People told us they would tell a member of staff or the manager if they were unhappy with their care or treatment. They said staff listened and they were confident that any issue would be satisfactorily resolved.

Staff told us that they had a very comprehensive induction when they began working for the home. An action plan would be agreed as to the training needs of the member of staff and development goals set. Staff said they felt really supported by the home and were happy with their supervision and appraisal arrangements.

People told us a resident’s meeting is held every three months. This provided a forum where they could put forward their suggestions or talk about issues they were not happy with.

Hill House Residential Home provides accommodation and personal care for up to 19 older people. At the time of our inspection there were 15 people living in the home.

We inspected Hill House Residential Home on 28 and 29 October 2015, this inspection was unannounced. During our last inspection on 5 September 2013, we found the provider satisfied the legal requirements in the areas that we looked at.

There was a registered manager in post when we inspected the service. 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. The manager was accessible and approachable. Staff, people who used the service and relatives felt able to speak with the manager and provided feedback on the service.

People were not informed by staff when the menu choice for the day was changed. When people received their lunch time meal it was placed in front of them unannounced and they were unable to have control over the portion size. One person who had been identified as having difficulties around swallowing and at risk of choking was left for large amounts of time unsupervised during the meal. The manager told us this would be addressed and there should always be a member of staff present in the dining room during meals.

The service had a strong commitment to supporting people and their relatives at the end of their life . The management team were determined that people should remain in the home being cared for by the staff they knew unless the home could not provide the level of care someone might need at end of life. Documentation that we looked at did not show that people’s end of life wishes were being reviewed, this meant that whilst good practice around end of life care was happening the records did not support this.

People told us they felt safe living at Hill House and they were well cared for. The provider had systems in place to manage risk and protect people from abuse. Staff had a good understanding of safeguarding and whistle-blowing procedures. They also knew how to report concerns and had confidence in the manager that these would be fully investigated to ensure people were protected. All of the staff we spoke with were knowledgeable about the requirements of the Mental Capacity Act 2005.

Safe recruitment procedures were followed and there was a comprehensive twelve week induction programme in place. Staff told us their induction prepared them well for their role and they were able to shadow experienced team members and get to know the people they would support.

People and relatives were very complimentary about the caring nature of staff. Staff were knowledgeable about people’s needs and people’s privacy and dignity was always respected. Staff explained the importance of supporting people to make choices about their daily lives. People told us they were involved in decisions about their care and systems were in place to monitor and review people’s changing needs.

There were clear policies and procedures for the safe handling and administration of medicines. People were supported to access healthcare services to maintain and support good health. Where people were at risk, the home worked alongside the community health professionals and put measures in place to support people.

The manager had effective quality and monitoring systems in place. This included a daily report from staff on events during a 24 hour period. The home actively encouraged feedback from people using the service, their relatives and staff. Feedback forms were available in the home and the staff had an expressions tree board to make comments on.