This inspection took place on 19, 20 and 21 November 2018 and was unannounced on day one.

At our last inspection we identified that the registered provider was in breach of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to safe care and treatment, safeguarding people from abuse, staffing and good governance.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions Safe, Effective and Well-led to at least good. During this inspection we found that although we could see that progress had been made in some areas, further improvement was still required in others. We found that the registered provider was in continued breach of regulation 12, safe care and treatment but was no longer in breach of regulations relating to staffing, safeguarding people from abuse and good governance.

Hill House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a 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 can provide accommodation for up to 23 people.

There was a registered manager in post however they were not present during the inspection and an interim manager had been appointed.

We found shortfalls in the safe and proper management of medicines. People’s associated risks were assessed however documentation and outcomes were confusing as two types and differing ratings were used.

We made a recommendation that the provider revisits an element of the service improvement plan with regard to consistent documentation relating to agency staff.

Accidents and incidents were recorded however we saw that managerial oversight and investigation needed to be more robust. We discussed our findings with the interim manager during the inspection and they developed a flow chart providing additional guidance to staff which included the need for regular managerial oversight.

Staff had received training and were able to demonstrate understanding of the procedures they would follow to protect people at risk of harm from abuse. People living at Hill House told us that they felt safe.

The environment was spacious, visibly clean and free from malodours. We checked safety certificates and found them to be in order. Regular fire drills were carried out. People had a personal evacuation plan (PEEP) detailing the support they would need in the event of an emergency and a business continuity plan was in place.

During the inspection, staffing levels appeared sufficient to meet people’s needs however we received varied views about this from people using the service and their relatives. People’s dependency levels were linked to an electronic system used to calculate staffing levels. Staff recruitment procedures were safe. Staff were supported and received the training they needed to carry out their roles effectively.

We saw that applications had been submitted as required where people were deprived of their liberty as required by the Mental Capacity Act 2005 (MCA). However, we saw that assessments of people’s capacity were carried out routinely for some decisions and this was not in line with the principles of the MCA.

Staff were inventive in achieving positive outcomes for people living at Hill House. Care was person-centred and people were treated as individuals. There was a programme of work underway to improve the quality of care plan documentation. The mealtime experience was observed to be positive and food was nutritious and of a good quality.

Conversion of a bungalow had been completed since our last inspection and provided activity and therapy facilities. The facilities would benefit from a covered pathway enabling them to be more accessible in bad/cold weather. Some people felt that there was not enough to do.

People were supported to access a wide rang

This inspection took place on 27 and 28 September 2017 and was unannounced.

The service was previously inspected in May 2015. The registered provider was complying with all regulations at that time..

Hill House is a care home providing both accommodation and nursing and personal care for up to 23 adults who have a physical disability. The service is provided by Leonard Cheshire Disability. The home is a modern purpose built facility and includes a bungalow separate to the main building. All bedrooms are single and have en-suite bathrooms fitted with overhead hoists. A passenger lift is installed to access the two floors. On the day of our inspection the service was providing accommodation and nursing care to 20 people.

There was a registered manager in post although they were not present during the 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.’

We identified four breaches of relevant legislation in respect of safeguarding service users from abuse, safe care and treatment and good governance. You can see what action we told the provider to take at the back of the full version of this report.

Overall the people and relatives we spoke with were positive about the care and support received at Hill House.

People told us that they felt safe from abuse and harassment and trusted the staff. However, we found that not all staff could demonstrate a clear understanding of the procedures they should follow if they witnessed or suspected that abuse had taken place. We were told about concerns by a member of staff and that they had not passed them on. As a result they had not been investigated or reported to the local authority and the Care Quality Commission (CQC) as required. This meant that people were not fully protected. We brought this to the attention of the deputy manager at the time of the inspection and it was then dealt with appropriately.

We saw that risk assessments had been recorded in people’s care records and that weight loss and pressure ulcer risks were regularly monitored. Accidents/incidents were not always recorded and we found that recording was not sufficiently robust.

Medicines were administered safely although we found that in some areas management systems needed to be improved. We saw that regular audits were taking place. There were two recent instances of missing medicines and we found that the process used for checking stocks needed to be reviewed.

At the time of the inspection we found that there were sufficient staff. Some people and staff told us that there were sufficient staff to meet their needs whilst others felt that this was not the case at night and weekend. We saw that staff received an induction and training was provided. Staff told us that they received the training and support they needed to carry out their roles effectively. Staff were also supported through supervisions although we saw that some were behind schedule. We found that safe recruitment systems were in place.

The environment was clean, spacious, fit for purpose and well decorated. Recent improvements had been made with the construction of an orangery extension and a sensory garden. Further works were planned to create an activity and physiotherapy centre within the grounds.

We were provided with two different versions of an emergency plan. We found that these lacked sufficient detail and guidance for staff in the event of a full evacuation. Following the inspection we received additional details which provided this information. A personal evacuation plan detailing each person’s individual needs was also in place.

We checked whether the service was working within the principles of the MCA, and whether any

We completed a routine unannounced inspection at Hill House Care Home with Nursing Physical Disabilities on 22 July 2013. During the course of the inspection, we spoke with three people who used the service and one family member visiting the home. We also spoke with the registered manager and five staff members.

The three people who used the service we spoke with told us overall that they were happy with the care and support provided by the staff. People told us they felt able to raise any comments or complaints they may have with the manager and staff. We found that there were systems in place to appropriately manage people's comments or any complaints raised.

One person who used the service told us: "The staff are kind," they also told us that they they did not feel rushed when staff attended to their needs. Another person who used the service said: "Care homes are much as I had feared and expected, here though the staff are supportive" and: "I talk more to the staff and volunteers than I do the people who live here, because of their ability to chat, but I enjoy speaking with them all."

We reviewed two care plans and found that they contained sufficient detailed information about how staff could appropriately support peoples' needs, including their choices and preferences. We found that before people received any care or treatment they were asked for their consent and the manager and staff acted in accordance with their wishes.

During our inspection 22 June 2012, we found that the staff recruitment files reviewed did not contain all the information required before staff were employed.

We revisited the home 27 September 2012 to review whether staff recruitment records and documentation had improved. We did not ask people using the service about this outcome.

We saw in the four staff files reviewed that the necessary security and employment checks were undertaken before staff were employed to work with people who lived in Hill House.

At the time of our inspection visit, 22 people lived in the home. We spoke with two people who used the service and three family members. We were told that they all took part in the decision-making around care planning, had attended meetings and were involved in the reviews of their care.

One person who used the service told us: "I am well supported and the food is good," and: "It's a very friendly place to be."

Another person said: "My views are listened to."

A family member said: "It's a lovely place to live and a top class home,” and another relative told us: "Staff act quickly if anyone is unwell and they let you know what's happening"

We were also told that the service surveyed people's opinions on all aspects of the care and support they receive.

People who use the service told us that they were treated with dignity and respect and they were involved in all aspects of their care. They also said they were happy living at the home and the care and support they received was good. People also told us that staff supported them to be involved in their care plans so that the care and support that they needed was given in a way in which they wanted.

People told us that on the whole the standard of food was good and they get plenty to eat.

They also said that they felt there where enough staff on duty to meet their needs. They felt that on the whole call bells were answered quickly and they did not have to wait too long for someone to come to them. We received comments such as “the staff are great”; “we can have a good laugh but they know what they are doing”; “I can trust the staff to look after me.

This inspection was unannounced and took place on the 11 and 14 May 2015.

The service was previously inspected in July 2013 when it was found to be meeting all the regulatory requirements which were inspected at that time.

Hill House is a care home providing both accommodation and nursing and personal care for up to 23 adults who have a physical disability. The service is provided by Leonard Cheshire Disability. The home is a modern purpose built facility and includes a bungalow separate to the main building. All bedrooms are single and have en-suite bathrooms fitted with overhead hoists. A passenger lift is installed to access the two floors.

On the day of our inspection the service was providing accommodation and nursing care to 20 people.

At the time of the inspection there was a registered manager at Hill House. 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.

Hill House had a registered manager in place that had been in post since October 2006. The registered manager was present during the two days of our inspection and engaged positively in the inspection process. The manager was observed to be friendly and approachable and operated an open door policy to people using the service, staff and visitors.

During the two days of our inspection, people living at Hill House were observed to be comfortable and relaxed in their home environment and in the presence of staff. People using the service and relatives spoken with were generally complimentary about the care provided at Hill House.

We observed interactions between staff and people using the service were kind, caring and personalised. We also observed people’s choices were respected and that staff communicated and engaged with people in a polite and courteous manner.

For example, comments received included: “I have lived in other homes and this was the cleanest one I have lived in”; The chef is very good and the food is lovely. In fact it’s too nice as I am trying to lose weight and can’t”; “The staff take me to the GP. I am going this afternoon”; “The GP visits Hill House quite often but the driver will take me to the optician or dentist if I need him to”; “You couldn't get better staff anywhere else”; “The staff will always approach me and keep me informed if needed”; “I haven't made a complaint but If I did I would go to Annie (manager), Linda (assistant manager) or the carers as they are all approachable. I am lucky that I can communicate” and “Annie (registered manager) is very approachable and is friendly with all of the staff.”

People using the service had access to a range of individualised and group activities and a choice of wholesome and nutritious meals. Records showed that people also had access to a range of health care professionals (subject to individual need).

We found that people using the service and / or their representatives were involved in person centred planning and received care and support which was individualised and responsive to their needs.

Systems had been developed by the provider to assess the needs and dependency of people using the service; to obtain feedback on the standard of care provided and to respond to safeguarding concerns and complaints.