This inspection was unannounced and took place on 31 October and 1 November 2017.

Hilltop Hall 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.

We last carried out a comprehensive inspection on 31 August and 1 September 2016. At this inspection we found the service to be in breach of the regulations relating to the management of medicines, recruitment practices, arrangements for the assessment of nursing residents prior to admission, the Mental Capacity Act (MCA) and deprivation of liberty safeguards (DoLS), staff training and quality assurance.

We returned to the service to carry out a focussed follow up inspection on 25 April 2017. Although we saw improvements had been made to arrangements for the assessment of residents in need of nursing care prior to admission, the Mental Capacity Act (MCA) and deprivation of liberty safeguards (DoLS) and staff training there were continuing breaches of medicines management, recruitment procedures and the management of the service. There was no registered manager in place at either of the above inspections and we were also concerned about the levels of agency staff being used at the home. The overall rating of the service was requires improvement.

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 all areas and plans were in place to make further improvements.

Hilltop Hall Nursing Home is situated close to Stockport town centre. The home provides nursing and personal care for up to 54 people. At the time of our inspection, 46 people were living at the home.

People who used the service had a diverse and wide age range of nursing and personal care needs. These included older people with age related health conditions, younger people with physical needs such as amputations and Multiple Sclerosis as well younger people who had a learning disability and/or mental health needs that may be challenging to others.

The service had a registered manager in place. The manager was registered with us on 17 August 2017 and had worked at the service since April 2017. 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.

At this inspection, we found that improvements had been made in relation to safe management of medicines and recruitment procedures. The numbers of agency staff being used by the service had significantly reduced.

The registered manager and deputy manager with support from the quality manager were more effectively managing the day-to-day operations of the service. The management team’s priority had been to reduce the use of agency staff and build a strong confident staff team to help provide consistent and safe care to people.

Staff had received training in safeguarding adults. Staff were confident that action would be taken by managers if they reported any abuse they witnessed or suspected.

Risk assessments were in place in relation to the environment and for people who used the service.

We found the home to be clean and tidy throughout and systems were in place to help control and protect people from infection.

The premises were spacious, well maintained and furnished to a good standard.

People gave mixed responses about the food provided. Plans were in place to improve the menu. We saw that people were offered

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

At our last inspection on 31 August and 1 September 2016, we found six breaches of the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulations 2014 relating to safe care and treatment, person centred care, need for consent, fit and proper persons employed, staffing and good governance.

Following the inspection the provider sent us a plan of the actions they intended to carry out to become compliant with 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 Hall Nursing Home’ on our website at www.cqc.org.uk.

Hilltop Hall is a care home situated close to Stockport town centre. The home is on a main bus route with a bus stop outside. There is ample parking for visitors' cars.

The home provides nursing and personal care for up to 54 people. At the time of our inspection, 48 people were living at the home. People who used the service had a wide range of needs, which included older people and some people who had a learning disability and mental health needs.

The service continued not to have 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.

Because there is no registered manager, we automatically limit the rating of the well led section of this report to requires improvement. Following our inspection we were formally notified that the acting manager had left the service and the operations support manager was to register with us as the manager of the service.

At our last inspection we found six breaches in the Regulations relating to the management of medicines, recruitment practices, arrangements for the assessment of nursing residents prior to admission, the Mental Capacity Act (MCA) and deprivation of liberty safeguards (DoLS), staff training and quality assurance.

At this inspection, we found that a number of improvements had been made, however the home remained in breach of three of the regulations in relation to the management of medicines, recruitment practices and quality assurance.

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

We also found that the following improvements had been made.

The deputy manager who was a qualified nurse was now undertaking pre-admission nursing assessments for people moving into the home.

We saw that applications for deprivation of liberty safeguards (DoLS) were being sent to the local authority DoLS team for consideration for authorisation. There was some evidence that the service was chasing the local authorities concerned for authorisation, however further work could be done to improve the recording system.

We saw that improvement had been made in the numbers of staff completing basic training.

The nurses were receiving clinical supervision from the deputy manager who was a qualified Registered General Nurse (RGN) and Registered Mental health Nurse (RMN). More recently care staff had started to receive more regular supervision.

This was an unannounced inspection, which took place on 31 August and 1 September 2016. We had previously carried out an inspection on 28 April 2014 when we found the service to be compliant with all the regulations that were in force at the time.

Hilltop Hall is a care home situated close to Stockport town centre. The home is on a main bus route with a bus stop outside. There is ample parking for visitors' cars.

The home provides nursing and personal care for up to 54 people. At the time of our inspection, 28 people were living at the home. People who used the service had a wide range of needs, which included older people and some people who had a learning disability and mental health needs.

The service did not have 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.

We found six breaches in the Regulations relating to the management of medicines, recruitment practices, arrangements for the assessment of nursing residents prior to admission, the Mental Capacity Act (MCA) and deprivation of liberty safeguards (DoLS), staff training and quality assurance.

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

Medicines were not always managed safely. This was because the administration of medicines was not always as prescribed. We also checked controlled drugs within the service. We found the cupboard used to store them did not comply with the law

Recruitment processes and systems in place within the service were not robust enough to ensure vulnerable people were protected against the risk of unsuitable people working within the service.

The acting manager, who was not suitably qualified to undertake the task, was carrying out assessments undertaken prior to admission for people who required nursing care.

We were concerned that the service had only started to make applications for the authorisation of the deprivation of liberty to the local authority in February 2016. We were told that 12 applications had been made but none had been authorised by the local authority. Records relating to the submission of DoLS applications were seen to be incomplete so we could not be sure how many or when the applications had been made.

Although staff told us that they received regular basic training from the service the records we saw did not support this. We saw that staff had not received regular supervision, which included the clinical supervision of all the nursing staff team.

The home had numerous quality assurance systems in place that showed areas were improvements were needed which in some cases remained outstanding. Not all the shortfalls we found had been identified in the services quality assurance systems particularly medication and recruitment.

Staff we spoke with us told us that they had received training and understood their reporting responsibilities in relation to safeguarding and whistleblowing on the poor practice of colleagues. Staff told us they were confident that action would be taken by the provider should they raise any concerns. We saw that in relation to a recent incident that this was the case.

Risk assessments were in place in relation to the environment and for people who used the service.

We found the home to be clean and tidy throughout and systems were in place to help control and protect people from infection. The premises were spacious, well maintained and furnished to a good standard. Plans were in place to undertake decoration in some communal areas of the home.

People gave mixed responses to the food provided. We saw that people were offered a choice of food and encouraged to eat as much as possible.

People had access to healt

An inspector visited this service on 28th April 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 caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

Is the service safe?

We saw that people were treated with respect and dignity by the staff. People we spoke with and some of the visitors to the home told us staff respected their privacy and dignity and supported them in a way that suited their individual needs and personal preferences.

The environment was clean, tidy and systems were in place to prevent, detect and control the spread of infections.

For the areas we looked at during this inspection visit we saw that staff had received appropriate training to ensure they had the knowledge, skills and experience to meet the assessed needs of people living at the home. This meant that people living at Hilltop Hall Nursing Home could be confident that their needs were being met by fully trained staff.

Systems were in place to make sure that managers and staff learned from events such as incidents, complaints, and safeguarding events. This reduced the risks to people and helped the service to continually improve.

We saw that policies and procedures were in place to support staff in delivering safe and effective care.

Management systems were in place to monitor and audit aspects of practice such as checks on care plans, medication audits, falls, hospital admissions, infection control and safeguarding people.

During our inspection visit we looked at the premises which were fit for purpose and we saw there were protocols in place to manage the ongoing maintenance of the home.

Is the service effective?

People living at Hilltop Hall Nursing Home had a care file that included assessments of their individual needs and risks. The care plan had been developed to meet those assessed needs. The assessments and care plans were reviewed on a monthly basis and updated accordingly.

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Prior to people being admitted into the home, where possible, a member of staff visited the person to carry out an assessment of their needs. This meant that people could feel confident that the service could meet their individual and personal care needs when they moved into the home. Where possible people could spend some time at the home having lunch and meeting staff and other people living at the home before a decision was made about moving in. We were told that relatives were encouraged to call in and look around the home at any time without having to make an appointment.

Is the service caring?

The atmosphere in the home felt relaxed, pleasant and friendly. From our observations we saw that care staff had a good understanding of people’s individual needs and preferences. We saw that staff were kind and sensitive in their approach to people and responded promptly to peoples requests or need for assistance.

We observed that people looked well cared for and were appropriately dressed.

Staff spoken with were all positive regarding the care that was delivered. Some comments included: “It’s a fantastic atmosphere here,” “I would be quite happy to come here,” “It’s so lovely here” and “We have a great staff team, the staff here are lovely and kind.”

Some of the comments we received from people living at the home were: “I have everything I need,” “I like having my hair and nails done” and “The girls here are nice people.”

Visitors spoken with confirmed they were always welcomed by accommodating, friendly and supportive staff. One visitor said “I can’t say anything bad about this 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 from the GP, the district nurse, the chiropodist, the optician and the speech and language therapist. This meant that people using the service received co-ordinated care and support.

The service had systems in place to ensure that people were regularly consulted about their views and ideas on how the home should be run. This was done by means of regular informal chats with people and satisfaction surveys. We saw evidence of these surveys being carried out on a regular basis, following which an analysis of the findings would be undertaken by the directors and an action plan would be implemented if appropriate.

Is the service well led?

The service worked well with other services to make sure people living in the home received appropriate care and assessment from the right professionals in a timely way.

When we looked at documentation we saw that there were good systems in place to audit and monitor care practices in the home. These actions helped to ensure that people received a good quality of service at all times.

When we spoke with staff they spoke highly of the support they received from the manager and the senior staff. They told us they received regular supervision and training. They also told us they had regular staff meetings and if they had any problem they would go straight to the home manager who was always available and approachable.

We carried out this inspection to check that concerns identified at our last inspection on the 16 April 2013 had been addressed.

We found that some improvements had been made. We saw that people were receiving regular health monitoring. We spoke with four members of staff who were able to describe the care that people needed and the audit systems that were in place to ensure that this was carried out. We also spoke with four people who lived at the home. They expressed no concerns and were complimentary of the staff.

Following the inspection we spoke with two relatives. We also spoke with the registered manager, who was not present on the day of the inspection.

We looked at the home's care documentation and saw that some improvements had been made within the records that the home used.

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

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

We spoke with three family members who used the service. They all told us that the home involved them in their relatives care and they were regularly consulted.

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 six people who lived in the home and all told us they thought that the home was good.

We looked at a selection of care records. We noted in two records that there was a lack of health monitoring to ensure that people’s needs were being assessed and care planned appropriately.

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

We viewed training records and found that there was training provided to enable people to deliver safe and effective care.

We found the lack of consistent recording systems means 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.