Archived: Hillview Care Home

Throughout June 2017, we received a number of whistleblowing concerns. In response to these, two inspectors carried out a third day of inspection on 3 July 2017 which was unannounced.

Hillview Care Home provides personal and nursing care for up to 53 people who live with a physical impairment, have a mental health condition, a dementia type illness or are living with a learning disability. Hillview Care Home is a large building within its own grounds in a residential area close to local amenities. There are gardens to the front and rear of the service with views of Eston Hills.

At the time of the inspection, there were 49 people using the service who were supported by the registered manager and 73 care staff.

The registered manager has been registered with the Care Quality Commission since May 2017; however they had been in post since 1 August 2016. 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.

People did not receive person-centred care because the care people were given did not always reflect their needs, wishes and preferences. Staff told us they did not have time to read people’s care plans and daily records did not match the needs identified in people’s care plans.

People were left in bed throughout each day of inspection. One person asked us if they were allowed to get out of bed. Outside of planned activities there was a lack of stimulation for people. Staff did not spend time sitting with people and talking to them. Staff told us they did not have time.

People’s privacy and dignity was not maintained or respected. We observed a nurse walk into a person’s room whilst they were receiving personal care without knocking. A used incontinence pad was left next to one person whilst they were laid in bed. Personal items such as urine bags, incontinence pads and nutritional supplements were on display. One person had been left on the toilet for three hours.

One person did not speak English. There was no information in the care records about how to communicate with this person such as key phrases and very little action was taken to seek alternative means of communication.

Prior to inspection, the Clinical Commissioning Group shared concerns with the management of medicines at the service. The registered manager had taken some action to address these concerns. We identified that the management of medicines needed to be improved. Medicines were signed for before people had been given them. Medicines were crushed without protocols in place. People did not receive their topical creams as prescribed. Nutritional supplements were not stored appropriately.

People at risk of malnutrition were not appropriately supported. Weekly weights were not consistently carried out. Risk assessments and care plans relating to these had not been regularly updated. We identified two people had not been given there breakfast by 11:30 on one of the days of inspection. One of these people was living wit a diagnosis of diabetes.

Staff were not responsive when people’s needs changed. We identified delays in responding to people, seeking treatment and obtaining prescribed creams. People at risk of developing pressure sores did not receive appropriate care and treatment. Staff failed to communicate clearly and care records relating to these were inaccurate, incomplete or had not been regularly reviewed.

Records showed people had been bathed at unsafe water temperatures between 20 and 36 degrees Celsius. Bins causing malodours had not been emptied. Incontinence pads and disposable gloves were not readily available for staff.

People’s personal information was not protected because we found care records on display on each day of inspection. Some staff shared personal information about people and the service with the public. The provider was taking action to address this.

There were gaps in all care records looked at. Care records were not regularly updated and some contained inaccuracies. Care plans were not always put in place when people moved into the service. This meant staff did not have the information they needed to provide safe care and support to people.

We raised concerns on the first day of inspection and asked for immediate action to be taken, especially in relation to the quality of record keeping. All concerns remained in place on the third day of inspection.

Quality assurance procedures were in place but had not highlighted the same level of concerns during this inspection. There were gaps in audits and information was not always clear. Action plans were put in place, however were not effective because staff did not carry out the tasks identified within them.

A strong and stable team who were supportive of each other was not in place. Staff were not accountable for their actions and did not follow the values of the service. This meant there was a lack of communication and team work.

There were insufficient staff on duty on the first floor of the service. Staff were not appropriately deployed on the ground floor. Call bells went unanswered.

Not all staff had received up to date training in fire safety, pressure area care and moving and handling. Competency checks had not been carried out for staff who lack confidence in using a new hoist. No training in learning disabilities, mental health and Parkinson’s disease had been made available for staff despite people with these health conditions using the service.

There were not enough hoists available for people on the first day of inspection. Although an order had been placed, no action had been taken to address the temporary shortfall. We asked the registered manager to address this during inspection. They took action and a further hoist was made available for staff.

The health and safety of the service was regularly monitored. Up to date safety certificates were in place and staff participated in regular planned fire drills.

Personal emergency evacuation plans were in place for each person and detailed important health conditions, medicines and any difficulties with mobility.

Staff training in safeguarding adults was up to date, however staff had not always raised concerns when needed. Where safeguarding alerts had been made, investigations had been carried out and actions put in place to minimise the risk of a reoccurrence.

Care staff had received regular supervision and appraisals, however not all nurses had received their appraisal. The provider already had an action plan in place.

People spoke very positively about the food provided at the service. Regular drinks and snacks were offered to people and each person had a jug of water or diluted juice in their rooms.

Health and social care professionals were involved in people’s care. Staff had not always shared information with health professionals in relation to pressure area care. Guidance from these professionals was documented in people’s care records. We found some care plans had been updated with this guidance, however others had not.

Staff had followed the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS) had been applied for and granted for 10 people. People are supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice.

Dementia friendly signage was on display in some areas of the service. The registered manager told us that this was an area for further development at the service. There were quiet areas available for people and there were flat outside spaces for people.

People spoke positively about the staff who provided care and support to them. We observed positive relationships between people and staff. Staff appeared to know people well. We observed laughing and joking and friendly banter between people and staff.

Care records showed that some people and their relatives had been involved in planning and making decisions about their care. The registered manager told us they regularly met with people and their relatives to discuss the care and support people received. Staff had organised for advocates to be involved in some people’s care to ensure their voice was heard.

People spoke positively about planned activities. Details about planned activities were on display and we observed people enjoying the performance by external singers and a visit from an ex-guide dog.

People knew how to make a complaint it they needed to. Each person spoken to told us they had confidence that the registered manager would take their concerns seriously. At the time of inspection no-one had wanted to raise a complaint. Concerns were raised outside of the days which we visited the service. We shared relevant information with the local authority and registered provider. We also considered these concerns during this inspection process.

Staff were generally supportive of the registered manager, had confidence in them and thought that improvements had been made since they came into post. Most staff told us they enjoyed working at the service and could approach the registered manager.

People told us they had confidence in the registered manager. People and staff told us they were kept up to date with changes at the service and upcoming events at meetings and via newsletters.

The service had links with the local community which included schools and religious organisations. The service held fundraising events

We gathered evidence against outcomes in relation to care and welfare, medicines and records which enabled us to answer three of our five key questions; Is the service safe? Is the service responsive? and Is the service well led?

We looked at a five sets of care plans, and spent time with the registered manager and nurse on duty. Throughout the inspection visit we also spoke with four care staff of varying roles and we spoke with four people who used the service and one relative.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who used the service, the manager and staff.

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

Is the service safe?

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The service had discussed the new legal judgement regarding DoLS with the local authorising body, and were completing applications for the people affected by this. We found that staff were not always aware of the needs of people who used the service when we asked them about people's needs that were recorded in their care plan. For example, one person who required supervision due to a choking risk was left alone in a lounge with a piece of fruit and a drink. The manager noticed and requested a staff member stay with the person whilst they ate and drank. This meant that people could be at risk of not receiving the right care or support.

We looked at five care plans out of 49 people who used the service and found two care plans were lacking in the recording of people's specific needs and how to meet them. We also saw that charts to monitor people's fluid and food intake and positional changes were not completed consistently. We have asked the provider to take action to address the issues regarding records.

We found that the service was not safe because people were not protected against the risks associated with the use and management of medicines. Whilst we saw some improvements since our last visit, there were still some issues which meant that people did not receive their medicines at the times they needed them and in a safe way. Medicines were not obtained, administered and recorded properly. We have asked the provider to address the identified issues regarding medication.

Is the service responsive?

We saw that although people were observed as being clean and well cared for and staff were attentive to people's needs, that the lack of care records and assessments meant some people were at risk of receiving poor care. People told us they thought the staff were helpful and one person told us of a specific example about how staff helped them promote their dignity.

Is the service well led?

We saw that audits were being carried out to check medication was being administered correctly, but action was not being taken to address the issues found, such as missing signatures or incorrect stock figures. This led to the audit being an ineffective 'tick box' process with no actions or analysis being used to improve the medication process. Other audits for care plans had not been completed on a consistent basis since our last visit at the end of May 2014.

The registered manager was trying to manage a large home with a number of people with very complex needs, without a deputy or clinical lead to support the day to day running of the service. We were told by the registered manager that nursing staff were not 'taking ownership' of tasks such as medication administration and recording, and this was the reason for the significant lack of improvement in these areas since our last inspection in May 2014.

The registered manager told us that the service had recently appointed a clinical lead and was waiting for them to commence employment. Another nurse had also been recruited and the service had been able to reduce the use of agency staff, which was positive. On the day of our visit, the service was short staffed due to someone ringing in sick at the last minute. The service did find another staff member to come in later in the day to assist. The registered manager stated that sickness levels had improved from when we visited the service in August, when concerns were raised about staffing levels. The registered manager also said the service had sourced support to assist with medication and care planning administration from another of the provider's services in the area.

What people told us: We spoke with three people who used the service, one relative and nursing and care staff.

One relative we spoke with told us; 'It's been brilliant. The food is great and the girls are lovely. If you ask for something you get it'.

One person who lived at the service told us; 'I enjoyed my breakfast this morning and I love living in this home'.

Another person told us; 'It's very good, it's more homely than hospital. You can ask for a cup of tea when you want. All the staff are brilliant, they are very helpful'.

One staff member told us; 'We are always very busy but it's a nice place to work'.

Below is a summary of what we found. The summary is based on our observations during the inspection, looking at care records and speaking with the manager, staff and people who lived at the service.

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

Is the service safe?

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The service had discussed the new judgement regarding DoLS with the local authorising body and were completing applications for people whom it was applicable in a prioritised approach as agreed with the local authority.

We found that staffing levels at the time of our visit were acceptable to meet the needs of the people living at the service. We discussed with the manager that on some recent occasions, staffing levels had fallen to seven care staff which was below the nine members of care staff that were scheduled to work during the day. The manager showed us the rota and explained that some staff had taken short notice leave and sick leave and that the service had made attempts to source cover from their own staff and from agencies. The manager explained they were currently recruiting for more staff to join the bank of staff available to the service. We looked at the rota for the forthcoming weeks and saw that there were always a minimum of eight staff rostered and on nearly every day there were nine or ten care staff rostered to work. Staff and people who lived at the service commented that at times recently there had not been enough staff, but when running at usual levels, the staffing levels could meet the needs of the people living at Hillview.

Is the service effective?

We saw that although people were observed as being clean and well cared for and staff were attentive to people's needs. We saw activities taking place and staff spending time with people chatting.

We saw that care records demonstrated people's needs were being addressed in a holistic manner which included people's emotional and communication needs. Care plans and assessments were reviewed regularly and one nurse told us they were receiving 1:1 support from the provider's quality officer to improve care plans to be more person centred.

What people told us: We spoke with three people who used the service, one relative and nursing and care staff.

One relative we spoke with told us; 'He's eating really well now and X is looked after smashing'.

'Once or twice we have had to wait when we ring but staff tell us they won't be long and they aren't.'

'I look at his daily book so I know what's happening with X'.

People using the service told us:

'Sometimes they are quite a while before they come when I buzz';

'At the moment there doesn't seem enough staff';

'Food wise I am fussy but they cater for everything';

'I can't fault the care I get here, I do like it here';

'Sometimes it's been short staffed with buzzers going';

'There is one staff member X, nothing is too much trouble for him'.

Staff members told us: 'I feel more able to talk to this manager than previous ones';

'Any niggles we can talk to the manager.';

'Nine staff on shift is brilliant, once or twice we've had six and we've been run off our feet' and

'She tries to get eight or nine on shift'.

The service had a registered manager in post. The management of the home was good and there was a positive environment for people and staff. Staff spoke highly of their manager and the support which they received from them and from one another.

Records showed that CQC had been notified, as required by law, of most of the incidents in the home that could affect the health safety and welfare of people. We saw action had been taken to ensure that we are now notified of all incidents.

During the inspection, the team worked together to answer five key questions which are outlined below.

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

Is the service safe?

People told us they felt safe and secure living at the home. Staff we spoke to understood the procedures they needed to follow to ensure that people were safe.

We found that people were not always receiving their medication correctly and medication records did not contain all of the information required by the Health and Social Care Act. The provider could not demonstrate that people were protected from the risks of unsafe or inappropriate care. A compliance action will be set in relation to this and the provider must tell us how they plan to improve.

We inspected the staff rotas which showed that there were sufficient staff on duty to meet people's needs throughout the day. However we could see that staff absences impacted upon the day to day running of the home. We saw action had been taken to address staffing levels.

At our last inspection we found gaps in the recording of information in people's records. At this inspection we saw that the manager had taken action however further work was needed. This meant that records still did not contain all the information required by the Health and Social Care Act. The provider could not demonstrate that people were protected from the risks of unsafe or inappropriate care because records were incomplete. A compliance action will continue in relation to this and the provider must tell us how they plan to improve.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. Policies and procedures were in place. Relevant staff had been trained to understand where an application should be made, and how to submit one.

Is the service effective?

People were given the care and support which they needed and this had been set out in their individual care plans. People and their relatives confirmed that they had been involved in developing care plans and reviewing care plans.

People had access to a range of health care professionals some of which visited the home. People told us staff escorted them to healthcare appointments if needed.

Some people spoke positively of the care that had been delivered and their needs had been met. Other people had concerns but we could see that appropriate action had been taken. People spoke positively about staff. We spoke with staff and could see that they had a good understanding of the people's care and support needs and that they knew them well.

Is the service caring?

At our last inspection a compliance action had been set because people's dignity was not always respected. We saw that action had been taken to address this. We observed good care practices and people's privacy, dignity and respect were maintained.

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people.

Is the service responsive?

Records confirmed people's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

People spoke positively about the range of activities which were provided at the home. We saw that people were able to participate in a range of activities both in the home and in the local community. Activities were available on an individual and group basis.

People and their relatives felt able to approach the manager and staff with any concerns which they had. They also confirmed that they were kept up to date with any changes which affected them and were involved in reviewing their plans of care when their needs changed.

Is the service well-led?

The home had a system to assure the quality of service they provided. The way the service was run had been reviewed regularly. Prompt action had been taken to improve the service or put right any shortfalls they had found.

Information from the analysis of accidents and incidents had been used to identify changes and improvements to minimise the risk of them happening again

People told us they had completed a customer satisfaction survey. People and relatives we spoke with confirmed they had been listened to and changes had been made where needed.

What people said

People who were able to express their views told us they were satisfied with the care and support they received. People were complimentary about the activities which were provided and about meals. One person told us, 'The dinners are marvellous. It's the best part of the day.'

People and relatives spoke positively about the care and support which they received. A relative told us, 'I can leave here reassured. I am confident in the care that is being delivered.'

Some people and their relatives made negative comments about the home but we saw that action had been taken to address these.

Staff spoke positively about working at the home and the support which they received. Staff were concerned about the impact of staff absence on the day to day running of the home but felt that when fully staffed, each shift was able to run smoothly.

Staff spoke positively of each other and of the support received from their manager. One staff member we spoke with told us, The staff are really helpful. They are all supportive of each other.' Another staff member told us, 'The manager always finds the time for you. They are open and I feel listened to. They respond to my concerns or queries when I need them to.'

The service had recently been fully refurbished and provided an extremely homely, spacious and comfortable environment for people to live.

We found that people were satisfied with the care provided at Hillview Nursing Home. They said, 'The staff are lovely and look after me well, I can't complain.' 'Staff understand my needs. My care needs are met.'

Relatives comments included, 'We are kept well informed of changes.' 'They really are lovely staff. They are polite and friendly, 99% brilliant.'

We spent time observing the interaction between staff and people living at Hillview Nursing Home. We found that there were occasions when people's dignity may have been compromised and people were left without staff engagement for periods of time.

Staff had a clear understanding of the protection of vulnerable adults and we found that there were arrangements in place to ensure that sufficient staff were available to meet people's needs.

Effective systems were in place for people to raise concerns and for them to be appropriately responded to.

We found that care records needed further improvement due to gaps and the need for additional information.

People also discussed how they found the new manager to be very approachable. One person told us that recently bank staff had been used and they found, at times, they were not as up to speed with how to best meet their needs. The new manager told us that since taking over the home this September she had taken steps to reduce sickness levels and ensure all staff knew how to work with the people. She acknowledged that at times bank staff were used but this had reduced in recent weeks.

Relatives thought the staff were excellent at their jobs and people were being appropriately supported. They told us that they had not needed to complain about the service and that since the new manager had taken over their opinions were sought more often. We were told that people who used the service views were sought about all aspects of the running of the home and this was done via residents meetings and surveys.

From our observations and discussions with the people we found that care staff worked in ways that supported the people and treated individuals with humanity as well as empathy.