We undertook an unannounced focused inspection of Hilltop Court Nursing Home on 8 and 9 May 2018. The inspection was prompted in part by a Regulation 28 Report we had received from the Coroner relating to evidence given at a recent Inquest. The information shared with Care Quality Commission about evidence given that raised concerns about the arrangements, supervision and management of risk of potential choking involving people who used the service. This inspection examined those risks and looked at what reasonable and practicable action had been taken by the registered provider to help reduce any future risks. We were not aware and were informed by the registered manager that no-one had died from choking at the home.

We also checked that improvements to meet legal requirements planned by the provider after our comprehensive inspection which was undertaken on 27 and 28 November 2017 had been carried out. These related to breaches of Regulation 12 of the Health and Social Care Act 2008 (Regulation Activities) Safe Care and Treatment and Regulation 17 of the Health and Social Care Act 2008 (Regulation Activities) Good Governance. The home was rated requires improvement in safe and well led with an overall rating of requires improvement. At this inspection although improvements had been made to the shortfalls we found at the last inspection, further shortfalls were found.

The registered provider sent us an action plan. This action plan was not yet out of the set timescale given by the registered provider. However, contact was made with the registered provider who agreed that we could check what improvements had been made since our last inspection. We also looked at additional continuous improvements made by the registered manager since our last inspection.

Because of the concerns we had received an adult social care services inspector and a specialist professional advisor (SPA) who was a qualified Speech and Language Therapist (SALT) undertook this inspection. A SALT is a qualified healthcare professional who provides treatment, advice, support and care for people who have difficulties with communication and/or eating, drinking and swallowing. At this inspection we only focussed on the safe and well led sections of the report. The last comprehensive inspection can be found on our website www.cqc.org.uk/sites/default/files/new_reports/INS2-3069399060.pdf.

Hilltop Court Nursing Home 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.

Hilltop Court Nursing Home accommodates up to 50 people on two floors in single sex units. The home provides care to people living with advanced dementia. A person who is living with the later stages of dementia is likely to experience severe memory loss, have problems communicating with others and need additional support with daily activities, including eating and drinking.

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 was a registered manager in place at the time of our inspection.

We found that the health and safety shortfalls we found at the last inspection had been satisfactorily addressed. Stairwells were kept free from electrical items, and the outstanding item on the homes fire risk assessment had been completed and signed off. A risk assessment had been carried out for mouse bait visible in the dining area and maintenance books had been to be signed off by a senior person.

We looked at the arrangements for monitoring nutrition and hydration for people including the risk of choking. We were told that when t

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

Hilltop Court Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises, the care provided, and both were looked at during this inspection.

Hilltop Court Nursing Home is situated close to Stockport town centre. The home provides nursing and personal care for up to 50 people. At the time of our inspection, 46 people were living at the home. People who used the service lived with advanced dementia. The home was on three floors named Coronation Avenue, Emmerdale Close and Wembley House.

We last carried out a comprehensive inspection on 31 August and 1 September 2016. At this inspection, we found the service was in breach of the regulations relating to the management of medicines and people's care and treatment records in relation to people's religious, cultural and end of life wishes and the availability of these records to all staff. The overall rating for the service was requires improvement.

We returned to the service to carry out a focussed follow up inspection on 25 April and 3 May 2017. Although we saw improvements had been made in relation to people’s care records, there were still shortfalls in the management of medicines. The service was rerated to good. It should be noted that changes in our methodology on 1st November 2017 a service can no longer be rated good if it is in breach of a regulation.

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 is the service safe and well led to at least good. At this inspection, we found that improvements had been made in relation to medicines management. However, we found concerns around the health and safety of the premises in relation to window restrictors and fire safety.

The service had a registered manager in place. 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 2008 and associated Regulations about how the service is run. The registered manager was present during most of this inspection.

We raised concerns about fire safety at the premises and requested a visit by the Greater Manchester Fire and Rescue Service. We also raised concerns about the lack of tamper proof window restrictors in parts of the home. Action was taken to address this matter during the inspection.

Although the registered provider’s quality assurance systems were identifying health and safety concerns, timely action to resolve them was not always taken.

You can see what action we have asked the registered provider to take at the end of the main report.

We recommend that all recent recruitment files are reviewed to ensure that the service is meeting requirements to ensure references are taken up with previous adult and children services employers.

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Staffing levels were sufficient to meet the needs of people who lived at the home.

Staff had received training in safeguarding adults. They were able to tell us of the action they would take to protect people who used the service from the risk of abuse.

Improvements had been made in medicines management. Systems were in place to reduce the risk of cross infection in the service; this included the use of personal protective equipment (PPE) where necessary and regular checks regarding the cleanliness of the environment.

Risk assessments were in place on people’s care records to minimise the potential risk of harm to people during the delivery of their care.

The registered manager understood the requirements of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). Th

This was an unannounced focused follow up inspection, which took place on 25 April and 3 May 2017.

At our last inspection on 31 August and 1 September 2016, we found two breaches of the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulations 2014 relating to safe care and treatment and person centred care.

Following the inspection the provider sent us a plan of the actions they intended to make to meet the relevant regulations. This inspection was carried out to check that the provider had met the breaches in the regulations. This report only covers our findings in relation to this topic. You can read the report from out last comprehensive inspection by selecting the ‘all reports’ link for ‘Hilltop Court Nursing Home’ on our website at www.cqc.org.uk.

Hilltop Court Nursing Home provides accommodation for up to 50 people who live with advanced dementia. There were 47 people using the service at the time of our visit.

The service had a registered manager in place, though they were not available 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.

At our last inspection, we found two breaches in the regulations related to the management of medicines and the lack of religious and cultural preferences on people’s care and end of life plans. Following the inspection the provider sent us a plan of the actions they intended to take to meet the relevant regulations.

At this inspection, we found that although significant improvements had been made the service was in continuing breach of the regulations in relation to medicines management. The breaches related to, incomplete medicines administration records (MAR), the arrangements for administering medicines covertly in food, the lack of ‘when required’ PRN protocols and temperatures to the medicines fridge temperatures.

You can see at the back of this report what we have asked the provider to do.

At this inspection, we found that the records relating to people’s religious and cultural preference had improved. Care records had been put onto a new electronic system and were accessible to staff at all times via laptops iPads, although the iPads were not operational during our visit. We were informed that 25 advanced care plans had been completed and the outstanding advance care plans were on-going with arrangements being made with families or solicitors. We were also informed that a Greater Manchester Ambulance Service liaison officer was also coming in to talk to families and relevant others of people who use the service. We recommend that the service completed the remaining records as far as practicably possible to do so.

This was an unannounced inspection which took place on 31 August 2016 and 1 September 2016. The service was last inspected on 28 October 2014. This was a follow up inspection and the service was found to be compliant.

Hilltop Court Nursing Home provides accommodation for up to 50 people who were living with advanced dementia. There were 44 people living in the service on the day of our inspection. We were not able to speak to people who used the service to ask them questions due to the nature of their diagnosis and lack of capacity. We therefore spoke with relatives and staff members and undertook observations around the service.

The service had a registered manager in place 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.

During this inspection we found breaches 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 this report.

Medicines were not always managed safely. This was because the administration of medicines was not always as prescribed, there was a lack of information available to staff on medicines that were to be taken ‘when required’ and one person was self-administering one of their medicines despite lacking capacity and with being risk assessed. We also checked controlled drugs within the service. A large surplus of one medicine could not be accounted for.

Staff members told us that although sometimes they felt as though there was not enough staff, they always managed to meet the needs of people who used the service.

We found risk assessments were in place in relation to the environment and possible hazards. Care records we looked at showed that individual risks to people had also been considered and protective factors identified to keep people safe.

Recruitment processes and systems in place within the service were robust. This meant that people who used the service were protected against the risk of unsuitable people working within the service.

We saw no evidence that nursing staff had received clinical supervision. The managing director could not tell us if these were being completed and the registered manager was not available to ask. We have made a recommendation that the service considers clinical supervisions for all the nursing staff.

Records we looked at showed that people had been assessed in relation to their capacity. These assessments had been undertaken by the relevant and appropriate people and had involved the person and their family. We also saw that best interest meetings had been undertaken for those people who lacked capacity to consent.

DoLS applications, which CQC should be made aware of, had been notified to us in a timely manner. We saw information to show that authorisations to deprive people of their liberty had been made to the relevant supervisory body.

We checked the kitchen and found adequate supplies of fresh, fresh, tinned and dried food was available. The service had a 5* rating from environmental health. All the relatives we spoke with told us the food was good. We have made a recommendation that the service considers current best practice guidance in relation to supporting people with advanced dementia during mealtimes.

Activities on offer within the service included, film night, board games, armchair exercises, ‘news and natter’, arts and crafts, entertainers, afternoon tea, karaoke and pyjama days. We observed one person was sat in the garden with their relative enjoying the good weather.

We looked at a number of policies and procedures during our inspection. We found these were robust and would support staff members in their roles.

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We carried out this inspection to follow up on concerns we found during our previous inspection on 9 and 12 June 2014. During that inspection we found that people were not cared for by staff that were well trained and supported to deliver care and treatment safely and to an appropriate standard.

During the previous inspection we also found that people were not protected from the risks of unsafe or inappropriate care and treatment because care records did not reflect their individual needs. We judged that this had a major impact on people using the service and enforcement action was taken against the provider.

Two inspectors visited the service on 28 October 2014 to carry out an unannounced inspection.

At the time of this inspection we were told that 44 people were accommodated in the home.

During this inspection we spoke with the manager, four members of staff, the director of care and looked at records.

We considered the evidence collected at this inspection and addressed the following questions, is the service effective and is the service well-led?

Below is a summary of what we found. Please read the full report for the evidence supporting our summary.

Is the service effective?

Since our last visit to the service we found there had been improvements in the training staff were receiving. Evidence was available to demonstrate that staff had received training in various subjects such as Dementia Care, Mental Capacity and Deprivation of Liberty Safeguards. The numbers of staff attending and completing each training course varied and the manager told us that all training was ongoing until all staff had completed all training relevant to their job role.

Is the service well-led?

At the previous inspection we had concerns that people were not protected from the risks of unsafe or inappropriate care and treatment because care records did not reflect their needs. Due to those concerns enforcement action was taken. During this inspection visit we found that the records relating to peoples individual needs had significantly improved but did still need some further development.

Staff were now receiving supervision on a more regular basis and the manager confirmed that she was planning for all staff to receive supervision at least bi-monthly and we will check this again at our next visit to the service.

We carried out this inspection in response to concerning information we received about the home regarding the temperature of the building during the night.

In response to the information received a compliance manager and a compliance inspector inspected the service during the early hours of the morning.

During our visit we spoke with the nurse in charge and the four care staff on duty.

We carried out this inspection in response to concerning information we received.

During our visit we spoke with a director of the service, the registered manager, the deputy manager and members of staff.

We spoke with four family members whose relatives used the service. They all told us that the home consulted with them on a regular basis and they considered the care to be good.

We used a number of different methods to help us understand the experiences of people using the service. This was because some of the people using the service had complex needs. We also spoke with three people who lived in the home and all told us that they liked living at the home.

We looked at a selection of care records. We had concerns regarding a person's plan of care.

We found although the service had some quality assurance systems in place, some were being developed.

The home had effective systems in place to ensure people were cared for in a clean and hygienic environment.

We viewed the training and supervision provided to staff and this was an area of concern.

We found the lack of consistent recording systems meant that there is a risk that information may not be kept up to date and people are not protected against the risks of unsafe or inappropriate care and treatment.

Two inspectors visited this service on 9 and 12 June 2014 to carry out an unannounced inspection. Prior to our visit we looked at all the information we hold on this service to help us to plan and focus on our five questions: is the service safe; is the service effective; is the service caring; is the service responsive; and is the service well led?

Is the service safe?

All the people who were living at Hilltop Court Nursing Home were living with dementia and could not always give their verbal opinions on the service they received. However, we observed during our visit that people were treated kindly and with respect. We were also able to understand from the people we spoke with that they were happy living at the home.

We saw and overheard one person to be displaying some challenging behaviour towards two staff at the home. From our observations and from talking to the two staff involved it was clear that they lacked the necessary skills and training to help them to effectively de-escalate the behaviour.

Each person had an individual care file that included some risk assessments and a care plan that described how to meet individual care needs. The care plans we looked at were found to lack detail of how staff should effectively meet peoples care needs and some identified care needs did not have a plan of care in place. These shortfalls meant that people could be at risk of not having all of their needs appropriately met.

Visiting relatives told us that they were pleased with the care their relative received.

During our visit we looked at the premises to see if they were suitable for their intended purpose. We found the premises to be suitable and there was evidence of ongoing maintenance at the home.

During the inspection we saw some areas that required extra cleaning. For example we saw the base of the hoist was dirty, there was an unidentified brown substance on the side of a small coffee table in the ground floor lounge and there was what looked like encrusted food on a pressure cushion on one of the chairs in the ground floor lounge. These issues were discussed with the director of care during this inspection and on the second day of inspection we were informed that the identified areas had been cleaned.

Is the service effective?

During this inspection we saw the quality of food provided was of an acceptable standard. We saw that choice was given with regard to the main part of the meal, however everybody was given the mash potato, vegetables and gravy without being asked if they wanted it. We saw that gravy and mash potato was served with Italian meatballs with pasta in a tomato sauce which seemed a strange combination. This was discussed with the management team during this inspection.

We looked at the staff training records and noted that staff had been provided with mandatory training but not other training relevant to their job role for example Dementia Care, Dignity in care and managing behaviour that challenges. Staff had not received adequate supervision or appraisals. This meant that people were at risk of not having their health and welfare needs met by trained, competent staff.

Is the service caring?

The atmosphere in the home felt busy and chaotic. Although staff were busy they were seen to be responsive to people’s needs. From our observations we saw that care staff had a good understanding of people's individual needs and personalities.

We observed that people were freely moving around the home.

The people we spoke with who were living at the home indicated that they were happy living at the home.

Is the service responsive?

We saw that where appropriate the service had accessed advice and care from other health care professionals. For example we saw evidence of visits to the GP, the chiropodist, the opticians and we saw that people attended hospital appointments. This meant the provider sought relevant professional advice and guidance appropriately.

Is the service well-led?

At the time of this inspection the newly appointed manager had only taken up post three days previously.

At the inspection in January 2014 we had concerns because records did not reflect the individual needs of people who used the service and placed people at risk of inappropriate care and treatment. Shortfalls were again found at this inspection and therefore enforcement action is being taken.