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 is not registered to provide nursing care. Hill House provides care for up to 37 people in one adapted building. At the time of this inspection there were 18 people living in the home and one person in hospital.

At our last comprehensive inspection on 1 February 2017, we rated the service good. Following that inspection, we received concerns relating multiple areas of the service. We carried out a focused inspection to look at these concerns on 30 October 2017. We found the service was not meeting the standards we inspected in relation to management and maintenance systems, staffing levels, medicines management and respecting people’s privacy.

At this inspection, we found that they had made the required improvements and were meeting all the standards. However, there were some areas that needed further development. This was in relation to the choice of food offered to people and building maintenance.

The service had a manager who was registered with the Care Quality Commission (CQC). 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.

People were supported in a safe and appropriate way and staff knew how to recognise and report any risks to people’s safety. Medicines were administered in accordance with the prescriber’s instructions. There were sufficient staff who were recruited safely and competent and well supported.

Areas of the building required redecoration. People’s health and nutritional needs were effectively met and monitored. People were provided with a balanced diet and staff were aware of people’s dietary needs. However, choice of meal was sometimes limited.

Staff knew the people they cared for well and understood, and met, their needs. People received care from staff who were trained and well supported. People were supported to access health care when they required it. People’s rights to make decisions about their care were respected. Where people did not have the mental capacity to make decisions, they had been supported in the decision making process.

People were treated with dignity, respect and kindness and were supported in accordance with their preferences and wishes.

People received person centred care in relation to their personal care and support needs. People were supported to access a range of activities, but this was an area for further development.

There was a complaints process that people knew how to use and were confident they would be acted upon. People, relatives, staff and care professionals made positive comments about the running of the service. There were systems in place to monitor the quality of the home, listen to people and value staff. The service worked in partnership with other agencies.

Following our last inspected on 1 February 2017, this service was rated as good. Since that inspection we have received concerns relating to, poor maintenance, insufficient staff, poor medicines management, staff assisting people to get up very early in the morning, staff not treating people with respect, insufficient food and cooking equipment, and records not stored securely.

This report only covers our findings in relation to these concerns. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for 'Hill House' on our website at www.cqc.org.uk.

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. Hill House is not registered to provide nursing care. Hill House provides a service to up to 37 people in one adapted building.

This unannounced inspection took place on 30 October 2017. There were 18 people receiving a service at that time.

The manager had worked at the service since March 2017. CQC was processing their application to register at the time of our 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.

There were not sufficient numbers of staff at the service at all times to meet people’s needs safely. Staff were only employed after satisfactory pre-employment checks had been obtained.

People were supported to manage their prescribed medicines safely. Staff were aware of the actions to take to report their concerns.

There were systems in place to ensure the building and equipment were maintained.

People’s private space was not always respected and people were not always involved in decisions about the care and support they received. People received care and support from staff who were kind and caring.

Audits of the service were not always effective. There were sufficient resources to ensure the running of the service. The manager was approachable and worked to improve the service.

Further information is in the detailed findings below.

Hill House is a residential care home registered to provide care to 37 older people, some of whom may be living with dementia. There were 17 people living in the home when we visited. The accommodation is on two floors and people have access to a number of communal areas and a large garden area whenever they wish.

At the last inspection the service was rated Good.

This inspection was undertaken on 1 February 2017 and was unannounced. At the last inspection we found the provider was in breach of one of the regulations that we assessed. This was in relation to the management of people’s medicines. We received an action plan from the provider which detailed the actions that that they were taking to improve the service. During the inspection we found that the required improvements had been made.

At this inspection we found the service remained Good.

People told us they felt safe living in the service. Risks to people were appropriately planned for and managed.

People told us there were enough staff to provide them with support when they needed it.

Staff had received appropriate training, support and development to carry out their role effectively.

People received appropriate support to maintain healthy nutrition and hydration.

The service was meeting the requirements of the Deprivation of Liberty Safeguards (DoLs). 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.

People told us and we observed that they were treated with kindness by staff who respected their privacy and upheld their dignity.

People were given the opportunity to feed back on the service and their views were acted on.

People received personalised care that met their individual needs. People were given appropriate support and encouragement to access meaningful activities and follow their individual interests.

People told us they knew how to complain and were confident they would be listened to if they wished to make a complaint.

The managers worked hard to create an open, transparent and inclusive atmosphere within the service. People, staff and external health professionals were invited to take part in discussions around shaping the future of the service.

There was a robust quality assurance system in place and shortfalls identified were promptly acted on to improve the service.

Further information is in the detailed findings below

Hill House provides accommodation and personal care for up to 37 older people including those living with dementia. Accommodation is located over two floors. There were 24 people living in the home during this inspection.

This inspection was unannounced and took place on 13 June 2016. The previous inspection took place on 19 October 2015 and overall was rated as good. However we had received concerning information about the care that was being provided to the people living at Hill House and as a result of this we brought the date of this inspection forward.

The home had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (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.

The CQC monitors the operation of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) which applies to care services. Staff had received training and had an understanding to ensure that where people lacked the capacity to make decisions they were supported to make decisions that were in their best interests. People were only deprived of their liberty when this was lawful.

Medicines were not safely managed and the medicine processes were not effective.

The provider had a robust recruitment process in place and staff were only employed within the home after all essential safety checks had been satisfactorily completed.

Staffing numbers were adequate to ensure people’s care needs were met.

Care plans provided detailed information on how people’s care needs were to be met this had been identified through their quality monitoring system. Staff were aware of people’s needs.

People’s privacy and dignity were respected at all times. Staff sought, and obtained, permission before entering people’s rooms to provide personal care.

People’s health, care and nutritional needs were effectively met. People were provided with a varied, balanced diet and staff were aware of people’s dietary needs. Staff referred people appropriately to healthcare professionals when this was needed.

Wherever possible people or their families were involved in the planning of the care people received.

The provider had an effective complaints process in place which was accessible to people, relatives and others who used or visited the service.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

Hill House provides accommodation and personal care for up to 37 older people including those living with dementia. Accommodation is located over two floors. There were 20 people living in the home when we visited.

This unannounced comprehensive inspection was undertaken on 19 October 2015. During the previous comprehensive inspection on 4 February 2015 we found the provider was not meeting all the regulations that we looked at. We found that there were breaches of four of the regulations and these were in relation to consent, complaints, completion of care records and the quality monitoring of the service. The provider wrote and told us of the actions that they would take to ensure that the regulations were met. During this inspection we found that these regulations had been complied with.

The home had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (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.

People were only offered a limited number and variety of hobbies and interests to take part in

Staff were knowledgeable about how to report any incidents of harm that people may experience.

People were looked after by enough staff who were trained and supervised to support them with their individual needs.

Satisfactory pre-employment checks were completed prior to staff working at the home. People were supported to take their medicines as prescribed and medicines were safely managed.

People had sufficient amounts and choice of food and drink.

People were supported to access a range of health care services and their individual health needs were met.

People’s rights in making decisions and suggestions in relation to their support and care were respected.

The CQC monitors the operation of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) which applies to care services. The registered manager was aware of the process to follow and had submitted a number of DoLS applications.

People were treated by kind and attentive staff. People’s care was provided based on their individual needs. There was a process in place so that people’s concerns and complaints were listened to.

Monitoring procedures were in place to review the standard and quality of people’s care.

Hill House provides accommodation and personal care for up to 37 older people including those living with dementia. Accommodation is located over two floors. There were 26 people living in the home when we visited.

This unannounced inspection was undertaken on 4 February 2015. During the previous inspection on 27 July 2014 we found the provider was not meeting all the regulations that we looked at. We found that there were breaches of three of the regulations and these were in relation to care and welfare of people, the premises and failure to inform the Care Quality Commission (CQC) of serious incidents. The provider wrote and told us of the actions that they would take to ensure that the regulations were met. During this inspection we found that these regulations had been complied with.

The home had a registered manager in post. This person was temporarily absent from the service as they were working and providing support in another of the provider’s locations. The deputy manager was managing the home in the manager’s absence and was being supported by the provider. A registered manager is a person who has registered with the Care Quality Commission (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.

The CQC monitors the operation of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) which applies to care services. There were policies and procedures in relation to the MCA and DoLS to ensure that people who could not make decisions for themselves were protected. However we found that the policies and procedures had not been followed and staff were not knowledgeable about submitting applications in relation to DoLS to the appropriate agencies. Records showed that where people lacked the capacity to make decisions they were not always supported to make decisions that were in their best interests.

Care records did not always reflect people’s current care and support needs. People were provided with sufficient quantities to eat and drink.

Staff respected people’s privacy and dignity at all times. They were seen to knock on people’s bedroom doors and wait for a response before entering. They also ensured that people’s dignity was protected when they were providing personal care. People told us that the staff were very kind.

The provider’s complaints process was available on the main entrance notice board but did not provide people with timescales by when the complaint would be investigated and where they could go if they remained unsatisfied with the response that they received. It was not clear from the complaint records if people were satisfied with the outcome of the investigations as the outcome was not clearly documented.

The provider had a recruitment process in place. Staff were only employed after all essential safety checks had been satisfactorily completed.

The provider had surveys in place to seek people’s views to identify areas for improvement. However an action plan had not been written to demonstrate the improvements that were to be made following people’s feedback. Audits completed did not always demonstrate where action had been taken when improvements had been required.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which correspond to breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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

We undertook this inspection in response to a number of concerns we had received in relation to staffing levels, a lack of hot water, laundry management and poor activity levels.

We spoke with three staff members, four people who lived in the home and viewed a range of documents including the staff rota and staff training records. We undertook a tour of the premises to check on health and safety matters.

SAFE

Staffing levels at the home were satisfactory and people’s requests for assistance were met in a timely way. However, we found a number of shortfalls with the premises which compromised people’s safety and wellbeing. Cleanliness in the home’s laundry was poor. Continued problems with the home’s water system meant that some people did not have hot water when they wanted it. We found there were inadequate arrangements for first-aid provision to ensure that staff could deal with a medical emergency.

The provider had, once again, failed to notify us of an important event that affected the welfare, health and safety of people who used the service so that, where needed, action could be taken.

CARING

The level and frequency of activities available to people at the home had reduced considerably since the activities co-ordinator had left. Information about the activities at the home was inaccurate and we found little evidence that the scheduled activities advertised had actually taken place.

We found that improvements were needed to laundry management systems in the home to ensure that people did not wear other people’s clothes.

Records of when people’s welfare had been checked were not accurate.

Prior to our inspection we had received some information of concern in relation to staffing and the home having no running water.

During our inspection we spoke with four members of staff, the manager, two visitors and eight people who lived at the home.

We considered our inspection findings to answer questions we always ask: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

This is a summary of what we found:

Is the service caring?

People who lived at the home and the visitors we spoke with told us they were very happy with the care and support that was provided by the staff. We observed people being treated with respect and staff ensured people’s dignity was maintained. People were encouraged to be as independent as possible.

Is the service responsive?

We saw that people’s needs had been assessed before they moved into the home. We found that care records we looked at were reviewed on a monthly basis and on the whole changes were made to the care plans.

Is the service safe?

During this inspection we looked around the home. We found that communal areas and some bedrooms were in need of decoration as they were looking tired. We were shown an improvement plan, which showed that some communal areas and bedrooms had been highlighted for re-decoration. Whilst it stated ‘quotes in place’ there were no timescales set for completion. Overall we found the home to be clean and tidy, with one shower room in need of a clean, which the manager addressed during our inspection.

Is the service effective?

People we spoke with were satisfied with the care they received from the staff at Hill House. Staff we spoke with understood people’s needs and told us they were well supported to deliver peoples care needs. Care plans gave staff clear guidance on each person’s needs.

Is the service well led?

Staff we spoke with told us they enjoyed their job and felt supported to do their jobs. Quality assurance records we looked at showed that although some of them identified some areas for improvement they did not all contain full details as to how these were to be addressed within a timescale. We found that the auditing system could be improved.

If you wish to see the evidence supporting our summary please read the full report.

During this inspection we did not speak to people who use the service. We were following up on the warning Notice that was served on 30 July 2013.

We found that improvements had been made to people’s risk assessments, their care plans and staff were able to tell us how they cared for and supported people.

At our previous inspection in May 2013 we found that the premises, the garden and the kitchen had not been well maintained and were unsafe. During this inspection on 24 July 2013, we found that overall improvements had been made and people were now safe.

We had concerns about the quality of information in people’s care records during our inspection in May 2013. Although we found that the format had been changed and was easier to read the information did not provide the required detail to ensure that peoples care and welfare needs were being met.

Staff were clear about the safeguarding procedures they should follow if they had any concerns that people were at risk of harm. .

The recruitment records that we looked at for three newly appointed staff showed that appropriate information had been obtained prior to them commencing their employment at Hill House. This ensured that the suitable checks had been carried out to assess the suitability of staff.

People we spoke with during this inspection told us they were happy and they were enjoying their evening meal. They were satisfied with the care they received. One person said, “the staff are lovely”. Another person told us they were well looked after.

During an inspection on 15 March 2013, we had found that the provider was not compliant with the regulations relating to medicines. This inspection on 23 April 2013 showed that improvements had been made with the medication procedures.

We had received some information of concern in relation to the care and welfare of people, staffing levels and over all cleanliness of the home. During this inspection, we looked at the care plans and noted that some improvements were required in relation to the information recorded which would ensure people’s needs were fully met. Whilst the cleanliness of the home was good, we noted that general maintenance, re-decoration and repair of the premises was required. Parts of the property needed attention, as they were looking worn and tired.

We found the staffing levels in the home were sufficient to meet people’s needs and staff felt supported in their roles and received appropriate training.

We visited Hill House on 15 March 2013 in response to information we received which alleged that some people who used the service were put at risk because there were insufficient staff to care for them. It was also alleged that people were not getting enough nutrition and there had been an error in medication.

During the inspection, we looked at the care files for three people who used the service. Whilst we noted that a number of people had lost weight during the last month, action had been appropriately taken to keep them safe and well.

We observed the care being provided and talked with staff who were very knowledgeable about the people who live at Hill House and were able to explain their needs. People we spoke with were all very happy with the care they received at Hill House and told us they were able to make choices.

We spoke with staff on duty who felt they were adequately staffed and felt well supported and appropriately equipped to do their job.

We looked at the medication administration storage, administration and disposal. We found that additional procedures need to be put in place to ensure people are not being placed at risk from medication omissions.

At the time of our last inspection, in September 2012, we told the provider that they had to make improvements as we had concerns about the lack of dignity and respect shown towards people. We also had concerns about the provision of staffing. The manager sent us an action plan which stated what improvements would be made. During this inspection, on 12 December 2012, we found that the necessary improvements had been made. People were provided with care and support in a more dignified and respectful manner. Improvements had also been made to the number of staff on duty and in the way that their work was organised.

During our inspection on 12 September 2012 we spoke with four people who lived in the home and two relatives. We used a number of different methods to help us understand the experiences of people living in the home. This was because some of the people had complex needs which meant that they were not all able to tell us their experiences.

People who lived in the home and their relatives spoke positively about the care provided at the home. One person told us, "I'm very happy here, I don't need to tell you anything else." Relatives said that they, and their relative, were involved in the care planning process. The majority of responses from people, and their relatives, was positive about the staff team, with one relative describing them as, "Excellent". However, one person did tell us that not all staff responded positively when asked for something.

This was also raised as an issue during a residents meeting.

During our observations we noted situations in which the dignity of people was compromised. These all related to the absence of staff in the areas in which people were and so there was no-one to notice that someone required assistance. We had concerns about the staffing levels provided, particularly with regard to the number of people in the home who were living with dementia. Whilst the layout of the home provided people with a choice about where to spend their time it also meant that staff were not able to provide support in all areas.

People who use the service had positive comments about the standard of care that they had received, one of whom described it as “excellent” and another person said the care and service was “very good”. They were also happy with how the home supported then with their medication. They felt safe from the risk of abuse and they liked the staff who looked after them. People with whom we spoke said they liked their rooms: one person added that this was because they were able to complement their bedroom with pieces of their own furniture.

During this review of compliance we have not asked any person who uses the service for their views about how the service respects or involves them. However, during our last visit on 04 April 2011, we received positive comments from people with whom we spoke and we have received no concerns or complaints since then.