This inspection took place on 21 February, 12 March and 3 April 2018. The first day of our inspection was unannounced and the two following days were arranged in advance.

Hilltop Manor Care Home Limited is a ‘care home’ in the village of Sherburn-in-Elmet. 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 and the care provided, and both were looked at during this inspection.

The service is registered to provide residential care for up to 35 older people, some of whom may be living with dementia, a physical disability, detained under the Mental Health Act or with mental health needs. At the time of our inspection 34 older people were living at the service.

There was a registered manager in post who was also one of the owners of the service. 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 2008 and associated Regulations about how the service is run.

At our last inspection in January 2016 we rated the service ‘Good’ overall. At this inspection the provider required improvement in the safe, effective, responsive and well-led domains. They were therefore rated Requires Improvement overall. This is the first time the service has been rated Requires Improvement.

Staffing levels at night were not safe. The provider did not have a robust system to assess, monitor and ensure staffing levels were safe.

At our last inspection we recommended the provider review the processes to support staff, with a particular focus on supervisions. These concerns had not been addressed and we found staff did not receive the required number of supervisions in line with the provider’s policy.

Staff completed training in areas the provider considered mandatory. However specific training, in areas such as dementia care and nutritional support, had not been consistently completed. We found three separate instances where staff required further medication training, due to medicine administration errors, and this had not been completed. The provider did not have a clear policy about how often the care worker’s competency to administer medicines should be assessed.

The provider had a programme of quality assurance checks to monitor the safety and quality of the service provided. The checks were limited in their scope and did not highlight the issues we found during our inspection. This increased the potential risk to people and resulted in a breach of governance.

We found breaches of regulation relating to staffing and the governance of the service. You can see the action we asked the registered provider to take at the back of the full version of this report.

The provider took some actions to address our concerns which included an increase of staff on duty at night, the development of a dependency tool to assess the minimum number of staff required and considered ways to improve their system of governance.

Risk assessments were completed when areas of risk had been identified. However, risk assessments and care plans were not updated when there had been a change in a person’s needs or following an accident or incident. Daily records highlighted issues but did not describe the follow-up actions taken by staff. Reviews of people’s support were completed but did not evidence they were included in discussions about their care.

Accidents and incidents were recorded, but we found these lacked detail about the management and response to the incident and any lessons learnt.

A fire risk assessment was completed in 2012 but there was record of this been reviewed to ensure it was still up to date. There were also no records of night staff having completed fire drills. Following the first day of our inspection a fire dr

This inspection took place on 13 January 2016 and was unannounced. The last inspection took place on 8 May 2014, and the service was meeting all of the regulations we assessed.

Hilltop Manor is a family run home in the village of Sherburn in Elmet. The service provides residential care and can accommodate up to 35 people. The service supports older people some of whom are living with dementia.

On the day of our inspection 29 people were living at the service.

The service had a registered manager. 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.

Staff were supported to attend regular training and told us they were well supported by the management team. However, supervision records we reviewed were not up to date. We have made a recommendation about this.

Some of the communal areas within the service were in need of redecoration and parts of the environment were not dementia friendly, for example they had patterned carpets and the handrails were the same colour as the wall. This meant people living with dementia were not consistently supported to be as independent as possible. We have made a recommendation about this.

People told us they felt safe. The service had sufficient staff to meet people’s needs and had effective systems which meant people could be assured staff were safely recruited.

Medicines were managed safely, staff had been trained to administer medicines and had an up to date policy which provided them with good practice guidance. The deputy manager took responsibility for medicines and we saw they completed monthly audits. This meant if any errors did occur they could be resolved in a timely manner.

People were protected from avoidable harm. Staff had a good understanding of safeguarding procedures and how to protect people from harm. There were detailed risk assessments and risk management plans in place which provided staff with clear guidance about how to reduce people’s distress and maintain their safety.

The registered manager and their staff team understood and worked within the principles of the Mental Capacity Act. Staff routinely sought consent and supported people to make their own choices.

People told us the food was good and we saw people had access to a choice of nutritious home cooked meals along with regular drinks and snacks throughout the day. The lunchtime experience was enjoyable for people.

The service worked with health and social care professionals to ensure people received the right support at the right time. People were supported to access routine health care such as the dentist, optician and community nursing team.

People received care which reflected their needs and was based on their individual preferences. People told us care staff ensured their dignity and privacy was met. Care plans contained information which provided staff with a sense of what was important to the person, they were reviewed and updated on a regular basis.

People knew how to make complaints although the service had not received any since our last inspection. People and their families provided positive feedback about the service.

The registered manager was known to people and their relatives, people told us they were confident the registered manager would resolve any issues they had. The registered manager understood their role and responsibilities and had a good measure of the strengths of the service and areas for further development.

Staff morale was good and all of the staff we spoke with told us how much they enjoyed working at the service.

During the inspection, we spoke to several staff, people who lived in the care home and their relatives. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

Below is a summary of what we found.

Is the service safe?

People were treated with dignity and respect by the staff. Safeguarding procedures were robust and staff understood how to safeguard the people they supported. Systems were in place to ensure that managers and staff learnt from incidents such as accidents. This reduced the risks to people and helped the service to continually improve.

The home had policies and procedures in relation to the Mental Capacity Act (MCA), 2005 and Deprivation of Liberty Safeguards. All staff had been trained to understand when an application should be made, and how to submit one. Documentation was available in people's care files to support this.

Staff had received up-to-date training in all mandatory areas, as well as those specific to their job role. Staff recruitment procedures were thorough and in accordance with the provider's policy. Staffing levels were determined based on the individual needs of each person living in the care home. Policies and procedures were in place to make sure unsafe practices were identified and people were protected.

People's dietary needs and preferences were documented and monitored. Staff understood how to identify risk of poor nutrition, dehydration or difficulty in swallowing.

Is the service effective?

Staff had the skills and knowledge to meet people's needs. Managers gave effective support to staff including induction training, supervision and appraisal. This was supported by a comprehensive training programme. The care home worked effectively with other agencies and health care services to ensure a co-ordinated approach to people's care was achieved.

Is the service caring?

People living in the care home were supported by kind and attentive staff. They were cared for sensitively and given encouragement. People's preferences, interests and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

The complaints procedure was understood by staff, people living in the care home and relatives. The registered manager was encouraging relatives to have greater involvement in the care offered.

Is the service well led?

There was a quality assurance process in place. Records showed that any adjustments needed were actioned promptly. This enabled the quality of the service to continually improve. Staff told us they were clear about their role and responsibilities. All of the staff we spoke to felt they were strongly supported by the managers.

We used a number of different methods to help us understand the experiences of people using the service, because the people using the service had complex needs which meant they were not able to tell us their experiences. We spoke to people who were visiting the home at the time of our inspection.

We saw that people were encouraged to make decisions for themselves or were

supported by the staff to make decisions about how they wanted to spend their time. We observed staff treating people kindly and with dignity.

People had care plans and risk assessments in place which helped staff to understand and meet their needs.

We saw that the staff wore personal protective equipment such as aprons and gloves where appropriate. The home had no malodours and we saw a comprehensive cleaning schedule was in place. These helped to minimise the risks of infections for people who lived here and for the staff too.

People who lived at the home were protected from risks of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. The staff we spoke with had received training in safeguarding adults.

Medicines were prescribed and given to people appropriately; we saw people were given the right medicine, in the right way and at the right time on the day of our inspection.

Records we looked at confirmed there were sufficient qualified and skilled staff on duty, each day, to meet people’s needs effectively.

The people who use the service told us that they were happy with the care that they received at Hilltop Manor. We spoke with eight people who all told us that they felt safe. One person told us, “I feel safe here” another person said, “I love it here, I like the people”. One person who uses the day care facility told us, “I wouldn’t come here if I didn’t like it!”

People receiving care were seen to be treated with dignity and respect by the staff. One person told us that, “it was strange to start with, but now no trouble, no worries.” Another told us, “I couldn’t fault the care it’s as if I am family.”

We observed the lunchtime meal and noted the positive interactions when the care workers shared their lunch with the people who live at Hilltop Manor.

People told us they had activities organised which they enjoyed. One person said “we sat outside and watched the jubilee parade and people spoke to us as they passed by”. We were told that cooking and playing the board games were two popular activities. We observed animals playing a part of the every day activities for various people who live here.

We spoke with two visitors who told us, “It is the little things the staff do, when someone is distressed, you can see them touching their hands and asking them what is wrong. They wander off happily together.” We were told they observed this through the window; it is not just because they are watching. They told us the, “care is incredible”

People told us that information about what the home could offer was provided to them or their representative so that where possible they could make an informed decision about whether the home could meet their needs. One person said ‘I discussed coming here with my relatives, then came in’.

The people who used the service told us that they were happy with the care and support that they received from the staff. People said ‘I love living here, the home is lovely’. Another person said’ I don’t have to worry about anything’. People receiving care and support were seen to be treated with dignity and respect by the staff. People said that they received help and support when they needed it. One person said ‘I get along with all the staff they are very good and help me, they know what I need’.

Medication systems in operation at the home had been improved since our last inspection. Staff were positive about the changes and people got their medication as prescribed to maintain their health and wellbeing. One person said ‘Staff bring my medication to me every time, there is no waiting’. A member of staff said ‘The new medication systems in place are better; they make us aware of people’s needs we are told at handover about new medications’.

One person said ‘I think my room is great’. The home environment was secure, clean and inviting. The cleaning at the home had been improved since our last inspection. One person said ‘Staff clean my room regularly’.

People spoken with said that they felt safe in the home and said that staff looked after them well. One person said ‘The staff are all kind I am very happy’.