Greenhill House 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. Greenhill House accommodates 37 people across two separate houses, each of which have separate adapted facilities. People who live at the home have complex physical disabilities. There were 37 people at the home on the day of our visit.

The inspection took place on 9 August 2018 and was unannounced. At our last inspection in May 2017 we found that the service had not ensured that all peoples' consent and best interest decisions were recorded in line with the Mental Capacity Act 2005 Code of Practice.

We also found at our last inspection that the lack of Mental Capacity training for staff had not been picked up swiftly by the provider’s quality monitoring systems. There were still areas that required improvement such as a review of best interest decisions and consent recording in care plans.

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 the service Effective? and is it well Led? to at least good.

We found that people's rights were now protected because there were effective systems in place to ensure that the requirements of the Mental Capacity Act 2005 were followed. This law protects people who lack capacity to make informed decisions in their daily lives. The provider had completed applications when needed under the Mental Capacity Act 2005 Deprivation of Liberty Safeguards. This helped ensure that the necessary safeguards were in place for the people concerned.

There was a registered manager for the service. 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 were positive in their views of the staff and the support given by staff with their range of needs.

People were treated in a kind and caring way by staff who staff spent plenty of time with people and engaged with them very positively. We saw that there were warm and good-humoured interactions between them.

People were supported to take part in a variety of social and therapeutic activities. Technology was used in an innovative way to promote independence and support people in their daily lives.

The provider’s quality monitoring systems were now effective. Areas of the service that required improvement such as a care plans, training and staff support and supervision were identified. Actions were taken to address any shortfalls in the service.

The last comprehensive inspection of Greenhill House (the service) took place in August 2016; at that time the service was in special measures having been rated inadequate following a comprehensive inspection in December 2015.

During the August 2016 inspection, eight breaches of the Health and Social Care (Regulated Activities) Regulations 2014 were found in relation to person centred care, need for consent, safe care and treatment, premises and equipment, staffing and good governance safeguarding service users from abuse and improper treatment, receiving and acting on complaints and requirement as to display of performance assessments. There was also a breach of Regulation 18 (Registration) Regulations 2009: in relation to notification of other incidents. We found there had been insufficient improvements to the service since being placed into special measures. The service remained in special measures and was rated inadequate for a second time. As a result conditions were placed on the provider’s registration to encourage improvement to the service.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements at its next comprehensive inspection and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We carried out a comprehensive inspection of Greenhill House on 24 and 25 May 2017. This inspection was unannounced. Regulatory breaches from the August 2016 inspection were followed up as part of our inspection. At this inspection the provider had made sufficient improvements to be removed from special measures.

You can read the report for previous inspections, by selecting the 'All reports' link for ' Greenhill House - Care Home with Nursing Physical Disabilities Nursing Home' on our website at www.cqc.org.uk

Greenhill House is a nursing home with a total of 37 beds. The service is split between two individual units; one providing residential care and the other providing nursing care to people living with physical disabilities. At the time of our inspection there were 37 people living in the service.

There was a registered manager in post. 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.

The provider had improved the quality monitoring systems which were used to bring about improvements to the service. Some improvements had yet to be embedded by the service.

The service had failed to ensure that best interest decisions were recorded effectively when people lacked the mental capacity to make decisions and give their consent. We have made a recommendation to the service about this.

Training in the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS) had been provided to staff. DoLS aim to protect people living in care homes and hospitals from being inappropriately deprived of their liberty. These safeguards can only be used when a person lacks the mental capacity to make certain decisions and there is no other way of supporting the person safely. Staff were knowledgeable about the protection of people’s rights.

Medicines were managed and stored safely. Medicine administration records were complete. We observed that medicines were administered to people as prescribed.

People’s needs were regularly assessed and resul

The inspection took place on 15 and 16 August 2016 and was unannounced. The last comprehensive inspection took place in December 2015 and at that time, six breaches of the Health and Social Care (Regulated Activities) Regulations 2014 were found in relation to person centred care, need for consent, safe care and treatment, premises and equipment, staffing and good governance. These breaches were followed up as part of our inspection.

At this inspection we found nine breaches of regulations. Five of the previous six breaches from the last inspection in December 2015 had been repeated. We also found three new breaches in relation to safeguarding service users from abuse and improper treatment, receiving and acting on complaints and requirement as to display of performance assessments. There was also a breach of Regulation 18 (Registration) Regulations 2009: in relation to notification of other incidents.

Greenhill House is a nursing home with a total of 37 beds. The home is split between two individual units; one providing residential care and the other providing nursing care to people living with physical disabilities. At the time of our inspection there were 37 people living in the service.

At the last comprehensive inspection this service was placed into special measures by CQC. At this inspection the overall rating for the service is ‘Inadequate’ and there is a continued rating of ‘Inadequate’ in the key questions of ‘Safe’ and ‘Well led’. This inspection found that there was not enough improvement to take the service out of special measures. CQC is now considering the appropriate regulatory response to resolve the problems we found.

There was 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.

Overall we found that quality and safety monitoring systems were not fully effective in identifying and directing the service to act upon risks to people who used the service and ensuring the quality of service provision. Many of the regulatory breaches identified at the last inspection in December 2015 been not been remedied.

The registered manager had failed to make appropriate statutory notifications; notifications tell us about significant events that happen in the service. We use this information to monitor the service and to check how events have been handled. The provider had not displayed the latest inspection rating for the service on its website.

The registered manager had failed to report and take prompt action as required regarding safeguarding and adverse incidents appropriately.

Not all the premises and equipment were not properly maintained.

Staff had not received regular supervision; the provider had not ensured that staff performance and progress was monitored effectively and that staff had an opportunity to voice their individual views. Staff told us that training did not meet people’s needs and we found that refresher training was frequently out of date.

Staff we spoke with had a good understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). The registered manager had made appropriate applications for DoLS where they had been required. These safeguards aim to protect people living in care homes from being inappropriately deprived of their liberty. These safeguards can only be used when a person lacks the mental capacity to make certain decisions and there is no other way of supporting the person safely.

Care plans and people’s risk assessments were incomplete and not reviewed as expected by the provider. Records used to monitor people’s health were not always completed.

The administration of people’s medicines was not in line wi

The inspection took place on 9 and 10 December 2015 and was unannounced. The last full inspection took place in December 2013 and two compliance actions were issued in relation to the safety and suitability of premises and records. These compliance actions were followed up as part of our inspection.

Greenhill House is a nursing home with a total of 37 beds. The home is split between two individual units’; one providing residential care and the other providing nursing care to people living with physical disabilities. The home also offers day care for up to five people each week day.

The overall rating for this service is ‘inadequate’ and therefore the service is in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

There was 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.

The quality and safety monitoring systems were not fully effective in identifying and directing the service to act upon risks to people who used the service. The compliance actions issued at the last inspection in December 2013 had not been met.

The home was not suitably clean. The hygiene practices of staff did not meet the Department of Health guidance for the prevention and detection of infection.

There were not sufficient numbers of staff to support people safely. We had feedback from staff, people and relatives that the current staffing arrangements did not meet the needs of people using the service. This was supported by our observations.

Care was not consistently person centred. Not all care plans were personalised and contained individual information and references to people’s daily lives.

Risk assessments did not always reflect actions required to reduce risks to people. We saw that appropriate action was not taken in response to unsafe incidents, including steps to reduce the risk of them reoccurring.

The administration of medicines was not in line with best practice.

The provider did not have an effective system to monitor records made by staff or records that related to the management of the service. Records used to monitor people’s health and record best interests’ decision making were not always completed.

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People said they liked living in the home and it met their needs. One person told us “I think it’s marvellous really.” The home had a relaxed, family atmosphere with people and staff chatting easily to each other. Staff showed a good understanding of people’s individual care and treatment needs.

The premises were designed with people with a disability. Equipment was provided to meet the needs of people with complex disability needs. We saw much of the home needed attention; this meant the home had an institutional appearance. The new manager had an action plan in place to modernise and redecorate the home, to make it more homely. The action plan had been commenced but many areas still needed to be addressed.

People made positive comments about the staff. One person described them as “fabulous.” Staff told us there had been improvements in staffing levels. One member of staff said staffing had “definitely improved” and another “there seem to be enough now,” about staff.

People’s records were not maintained in a consistent way. Staff knew about people’s care and treatment needs but matters they told us about were not documented. Records relating to prevention of pressure ulceration and skin care did not show how staff were preventing risk of tissue damage for people. Risk assessments were not consistently completed in accordance with national guidelines.

People told us, overall, they were able to get up at the time they preferred. One person said, “it’s definitely improved. Now I’m getting up at the time I would like to get up. Another person said, “staff come when I want them to. Yes, I get up when I want to. I have no complaints.”

We found the provider had made some changes to the way work was organised in the morning. There was an additional member of staff to assist with breakfasts at the weekend. We saw some staff on the morning shift started 30 minutes earlier and there was an additional member of staff between 7am and 7.30am to assist people with their care needs.

Staff we spoke with thought the changes the provider had made enabled people to get up and receive support with their personal care routines at their preferred time.

We spoke with four people. Most people told us they were satisfied with the care. One person told us " they look after us OK."

We observed staff were patient and caring. There were some risks to people because there were not sufficient numbers of staff to meet people's needs. We found people often had to wait until late in the morning to be helped to get out of bed, washed and dressed to start their day. This meant some people had breakfast near lunchtime or missed morning activities.

People told us that they were supported to make choices and their independence was respected and enabled. One person told us they were supported by staff to use the cooker to make food of their choice. Another person told us that they were involved in local community forums and a number of people attended a local college.

People were asked for their views in a variety of ways including meetings and feedback forms.

People and their relatives told us that overall they were pleased with their care and the support provided. One person told us “You have to be honest, the care is outstanding”

People's care was delivered in line with regularly updated assessments and plans of care.

People were offered a choice of what to eat and drink, although people’s opinions on the quality of the food varied. People’s nutrition and hydration was being assessed and appropriate support was given to maintain weight.

We found that the building was suitable for the people who lived there and we were told that there were plans for some improvements to be made to the communal parts of the building.

We found that there were appropriate systems in place to monitor quality and manage risks.

There were some risks to people because there were not sufficient numbers of staff in the morning, or to cover sickness. We found that people often had to wait until late in the morning to be helped to get out of bed and washed and dressed ready to start their day.

We carried out this review to check that the provider had made improvements following our compliance review in January 2011. We visited the service but we did not speak to people who use the service as part of this review. We met and talked with the manager and seven members of staff. Staff told us that they were receiving regular supervision and that equipment was now being correctly cleaned and replaced as appropriate.

During our visit to the home people made many positive comments, which included:

‘I feel that staff keep me informed and this has improved during the last year to six months. I have a meeting every three months with my main nurse’

‘I like it here the staff are gentle and pleasant’

‘Staff keep me up to date on what is happening, especially the physio’

‘When I want to do things they let me as long as there are enough staff’

‘I do have one to one time with staff, but feel that this is not as often as I would like due to staff being very busy’

‘Staff respect my privacy and all are very nice’

‘My family are told what is happening with my care’

‘This is the best home as they let me do what I want independently, I’m happy here’

‘I feel able to make a complaint and my family can speak to the staff’

‘I think there is a shortage of domestic staff. Also I would like the nursing and care staff to spend more time talking to me’

‘Staff can be busy but they always come if it is urgent’

When we visited the home we found some aspects of care needed improvement. We found that the qualified nursing staff need more support to help them provide leadership for care standards in the home. This may have contributed to other concerns we had such as people not being adequately protected from the risk of cross infection.