About the service: North Hill Nursing Home is a ‘care home’ that provides personal and nursing care plus accommodation for a maximum of 31 adults, of all ages, with a range of health care needs and physical disabilities. At the time of the inspection there were 24 people living at the service.

What life is like for people using this service:

Since our last inspection the provider has been more visible in the service and reviewed how the service was run. Changes were made to improve the quality of care for people and staff at the service. Staff now had delegated roles and responsibilities so were more accountable for the quality of care they provided. The management team had worked as a strong team to mentor and empower the staff to make improvements to the support people received.

Checks had been completed to help the provider understand if improvements were being made. The checks did not always highlight areas for improvement, or where they did we saw action plans were not recorded effectively. These systems needed to work better to ensure safety and

quality for people.

People, their relatives and the staff all told us they felt more confident in the leadership and management of the service. Good staffing levels afforded people responsive and dignified support.

Staff morale was good and everyone was committed to ensuring people received care and support based on their preferences and choices. People told us they felt safe, and liked living at North hill house and enjoyed the range of activities and felt well cared for. People said they were always treated with respect. Care staff were eager to be involved in the social aspects of people's lives, which demonstrated their commitment to people's overall wellbeing.

Positive changes were seen at this inspection and the motivation for continuous improvement was demonstrated by the staff team within the service. More robust systems would support the provider to make further change to sustain improvements made.

More information is in Detailed Findings below

Rating at last inspection: Requires Improvement (report published 19 April 2018)

Why we inspected: This was a planned inspection based on the rating at the last inspection. At our last inspection we rated the service Requires Improvement and found the service was in breach of the regulations in relation to person centred care, safe care and treatment, staffing, absence of notifications of incidents and good governance. As a result, we issued five requirement notices. We subsequently met with the provider to check action was being taken to improve the service.

At this inspection we found that the provider had complied with some of the breaches of regulation, in the areas of person centred care and notifications of incidents were now reported. We also found that some improvements had been made to other breaches of regulation in the areas of staffing and good governance. We acknowledge that the care for people had improved and people were at less risk. However, there had been insufficient time for these changes to be fully embedded to ensure long term sustainability, hence the rating remains Requires Improvement.

Enforcement/improvement action we have told the provider to take.

Please see the ‘action we have told the provider to take’ section towards the end of the report.

Follow up: We will carry out a further focused inspection, in line with our inspection programme, to check improvements have been made to ensure the service is meeting the regulations. We will continue to monitor intelligence we receive about the service. If any concerning information is received we may inspect sooner

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

North Hill Nursing Home is a ‘care home’ that provides accommodation for a maximum of 31 adults, of all ages, with a range of health care needs and physical disabilities. At the time of the inspection there were 24 people living at the service. 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.

North Hill Nursing home provides accommodation. Some bedrooms are on the ground floor where communal areas are also present. The remaining bedrooms are on the first floor which is served by a lift. Staff are present on both floors of the home at all times to ensure people’s needs are met.

This service is owned by a sole provider and, as the ‘registered person’, the provider is responsible for the day-to-day running of the service. 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.

We carried out this unannounced inspection on 19 February 2018. At the last inspection, in September 2015, the service was rated Good. At this inspection we found the service to have an overall rating of Requires Improvement.

Prior to the inspection we received three anonymous whistleblowing concerns regarding the service. These were in relation to staff attitudes, training and management approach. The majority of staff told us they did not feel able to raise concerns with the management team. The provider and charge nurse were aware that there was low morale in the staff team. They held a staff meeting where it was acknowledged that there was lack of team work and that staff were not completing tasks in a timely or appropriate manner. Whilst the issues were acknowledged and addressed by managers, some staff thought there was no action plan from the management team in how to move this forward for the benefit of staff or the people they supported.

From this inspection we found inconsistencies in how management addressed issues with staff conduct. There was limited or no documentation to evidence if the staff members conduct had been raised with the individual, how it had been addressed and what action was to be taken. This meant there was a lack of confidence in how the management team addressed staffing issues which could impact on the staff team and on the people they supported.

We also identified there was no robust system of effective auditing in place and therefore the provider and charge nurse were unable to identify or address areas of significant concern. For example, we found that care plans were not in place for one person at the service, and that care plans generally were not up to date to reflect people’s current care needs. Risk assessments, for example falls assessment, had not been reviewed when people’s needs had changed, to see what preventive measures needed to be put in place to minimise the potential for further falls. We concluded that people’s care plans did not provide staff with sufficient accurate information to enable them to meet people’s current care needs.

People were supported to take their medicines by nursing staff who had been appropriately trained. However, medicines management was not fully robust. The stock of medicines that had been prescribed for people did not tally with records held at the service. This meant that the service could not account for all medicines held at the service or be confident that people’s medicines were being stored and administered safely.

We found recruitment processes were not followed consistently. We also found that staff induction, supervision and appraisal had not occurred for some time. In addition staff training was not up to date. Therefore staff were not being supported to maintain and develop their skills in line with current best practice.

Some people needed help from staff to move from

We carried out this unannounced inspection on 27 May and 1 June 2016. The service was last inspected in August 2014; we had no concerns at that time.

North Hill House is a care home that can accommodate up to 28 older people. At the time of our inspection there were 25 people living at the service.

This service is owned by a sole provider and, as the ‘registered person’, the provider is responsible for the day-to-day running of the service. 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 told us they felt safe living at North Hill House and with the staff who supported them. Comments from people and their relatives included, “No concerns, very good” and “I am very happy living here.” A healthcare professional said, “It’s brilliant. Everyone seems happy and chatty when I visit.”

During our inspection there was a relaxed and friendly atmosphere at the service. We observed people had a good relationship with staff and staff interacted with people in a caring and respectful manner. Relatives said, “They [staff] do everything possible for [person’s name]” and “Staff are lovely. Really caring of me and [person’s name].”

People took part in a range of group and individual activities of their choice. Where people stayed in their rooms, either through their choice or because they were cared for in bed, staff spent one-to-one time with them. This helped to prevent them from becoming socially isolated and promoted their emotional well-being. There were sufficient numbers of suitably qualified staff on duty and staffing levels were adjusted to meet people’s changing needs and wishes.

Staff completed a thorough recruitment process to ensure they had the appropriate skills and knowledge. Staff knew how to recognise and report the signs of abuse.

People had access to healthcare services such as occupational therapists, GPs, chiropodists and dieticians. Relatives told us they were confident that the service could meet people’s health needs and they were always kept informed if their relative was unwell or a doctor was called.

Staff supported people to maintain a balanced diet appropriate to their dietary needs and preferences. A newly recruited ‘hotel service manager’ had sought people’s views about the meals provided and, as a result of the comments received, menus had been changed. One person told us, “The catering wasn’t so good. Since [name of hotel service manager] joined it has improved a lot.”

Care records accurately reflected people’s care and support needs. Details of how people wished to be supported were individualised and provided clear information to enable staff to provide appropriate and effective support. Any risks in relation to people’s care and support were identified and appropriately managed.

Management and staff had a good understanding of the Mental Capacity Act 2005 (MCA). Where people did not have the capacity to make certain decisions the management and staff acted in accordance with legal requirements under the MCA. Staff applied the principles of the MCA in the way they cared for people and told us they always assumed people had mental capacity.

People and their families were given information about how to complain. People told us they knew how to raise a concern and they would be comfortable doing so. There was a management structure in the service which provided clear lines of responsibility and accountability. Staff had a positive attitude and the management team provided strong leadership and led by example. Staff said, “Communication is good” and “It’s absolutely lovely working here.”

Effective quality assurance systems were in place to make sure that any areas for improvement were identified and addressed. Management were visible in the service and regularly observed and talked to people to check if they were happy and safe living at North Hill House.

We gathered evidence against the outcomes we inspected to help answer our five key questions: is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and the staff told us.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

During our inspection of North Hill Nursing Home we saw evidence to support a judgement that this service was safe.

People were treated with dignity and respect by the staff. During our inspection we spoke with eight people living in the home and six visiting relatives. People told us they were very happy living in the home and they felt safe. One person told us “I am very happy here”. Relatives told us “X is very happy here” and “I can’t recommend the home enough”.

Care plans were personalised to the individual and gave clear guidance for staff to follow to meet people’s needs. Care staff told us the nurses were good at updating them about people’s health needs and all staff worked together well to ensure people’s needs were met.

People were safe because staff knew what to do when safeguarding concerns were raised and they followed guidance.

We saw North Hill Nursing Home understood the legal requirements of the Mental Capacity Act 2005 and the associated Deprivation of Liberty Safeguards.

We found there were enough qualified, skilled and experienced staff to meet people’s needs.

Is the service effective?

During our inspection of North Hill Nursing Home we saw evidence to support a judgement that this service was effective.

People’s health and care needs were assessed and mobility and equipment needs had been identified in care plans where required. Staff we spoke with and observed showed they had good knowledge of the people they supported.

We spoke with six visitors and they all confirmed they were able to visit the home whenever they wished. One relative told us they provided personal care for the person when they visited and the home had supported them to do this.

Is the service caring?

During our inspection of North Hill Nursing Home we saw evidence to support a judgement that this service was caring.

People’s individual care plans recorded their choices and preferred routines for assistance with their personal care and daily living. We saw staff provided support in accordance with people’s wishes.

Everyone we spoke with told us staff were caring and attentive to their needs. One person told us “they [staff] are wonderful”. Relatives told us “there is good, kind interaction by staff” and “I am happy for staff to look after X”. We observed staff responded to people in a kind and sensitive manner.

Is the service responsive?

During our inspection of North Hill Nursing Home we saw evidence to support a judgement that this service was responsive.

The home employed an activities co-ordinator, who worked at least three days a week, to facilitate group activities such as; card games, bingo and darts. Another worker was allocated to spend one day a week talking and reading to people individually who were bed bound or chose to stay in their rooms. This meant that activities were provided to support people’s individual needs.

North Hill Nursing Home gave clear information to people about how to complain. The home had not received any complaints in the last year. We saw that because of the open culture of the home, people were happy to give feedback or raise concerns as soon as situations occurred. One relative told us whenever they raised any concerns these were listened to and dealt with promptly. This meant that any concerns were dealt with quickly and resolved without the need to formally complain.

Is the service well-led?

During our inspection of North Hill Nursing Home we saw evidence to support a judgement that this service was well-led.

The home worked with other services to ensure people’s health needs were met. This included professionals such as GPs, dieticians, speech and language therapists and tissue viability nurses.

It was clear from people and relatives we spoke with that the manager and owner were visible in the home and involved people in decisions made about the running of the home. Staff we spoke with told us the management team were very approachable and welcomed any ideas or suggestions from staff.

Quality assurance systems were in place to monitor the service being provided and where shortfalls were identified these were addressed. At a result the quality of the service continuously improved.

North Hill House provided care and support to a maximum of 27 people. There were 27 people who used the service at the time of our inspection.

This was a planned inspection to follow up a compliance action made at the last inspection about assessing and monitoring the quality of the service.

We saw care plans were detailed and gave direction as to the care and support people needed. They had been regularly reviewed.

The home was clean and hygienic whilst remaining homely.

The home was well maintained and there was an ongoing improvement and redecorating plan in place.

We saw there was enough qualified, skilled and experienced staff to meet people’s nursing, care and social needs.

On the day of the inspection there were 26 people living at North Hill House. They all required nursing care. There was a trained nurse on duty 24 hours a day.

People who lived at North Hill House told us staff were helpful. One person said “everybody is nice here and I get the help I want”. During our inspection we saw and heard staff interacted with the people in a friendly and professional manner.

Although each person had a care plan they were not detailed enough to direct as to the care and support each person needed.

People told us they enjoyed the meals. We saw people who needed help with their meals received assistance in a discreet manner. We saw specialist diets were catered for and managed well.

We were shown there was a robust system in place to obtain medicines from the pharmacy for people who lived in the home. This meant that people received the correct medication at the correct time.

Everyone we spoke with was satisfied with the service they received. We saw the staff training programme was much improved since our last visit. Staff told us there was regular access to training either on line, by external providers or in house.

There was no satisfactory formal quality assurance system in place. This meant it was not clear how the ongoing quality of the service was managed. We saw the provider knew the people that used the service and they, as well as the staff, were happy to approach him about anything they wished to discuss.

People told us that the staff were “marvellous” and “couldn’t be better”. They said they could have visitors when they wanted and there were ‘things to do’ if they wanted to join in.

We saw that the routines being observed during the site visit showed that people were able to choose how and where they spent their day.

People told us they were happy with the care they received at North Hill House.

They said that the staff were “approachable”, “cheerful” and “kind”.

People told us that they could talk to any member of staff if they had any concerns or questions. One person mentioned that the Charge Nurse is very approachable.