About the service: Hill 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. It provides accommodation for people living with a learning disability. The home can accommodate up to 35 people. At the time of our inspection there were 14 people living in the home. This is larger than current best practice guidance. However. the size of the service having a negative impact on people was mitigated by the location.

The service had been developed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with a learning disability were supported to live as ordinary a life as any citizen.

People’s experience of using this service:

There was a system in place to carry out quality checks. The home manager had started to carry these out on a regular basis, however these checks had not been in place long enough to understand the impact these would have on the service.

Medicines were not consistently managed safely. Arrangements were in place to monitor and manage medicines but these had not identified the issues we found at inspection.

People said they felt safe. There was sufficient staff to support people.

People enjoyed the meals and their dietary needs had been catered for. This information was detailed in people’s care plans.

Staff followed guidance provided to manage people's nutrition and pressure care.

The care plans were in the process of being reviewed. Care plans contained information about people and their care needs.

Staff had received training to support their role.

Staff had started to receive supervision and plans were in place to ensure people received this on a regular basis.

People had good health care support from professionals. When people were unwell, staff had raised the concern and taken action with health professionals to address their health care needs. The provider and staff worked in partnership with health and care professionals.

Staff were aware of people's life history and preferences and they used this information to develop positive relationships and deliver person centred care. People felt well cared for by staff who treated them with respect and dignity.

There was a range of activities on offer. The home manager was looking at how they could develop this area further.

The environment was adapted to support people living with learning disability. A refurbishment plan was in place to address this. The home was clean and arrangements were in place to manage infections.

The provided had displayed the latest rating at the home and on the website. When required notifications had been completed to inform us of events and incidents.

More information is in the detailed findings below.

Rating at last inspection: Requires Improvement (Report Published 11 April 2018). At our previous comprehensive inspection in February 2017 the service was rated overall good. However, a focussed inspection was carried out on 11 April 2018 following concerns raised. We looked at three domains safe, caring and well led. We found a breach of Regulation 17 HSCA 2008 (Regulated Activities) Regulations 2010.The service was rated overall Requires Improvement at this inspection.

At this inspection we found the regulation was being met. There were improvements in the quality monitoring systems. However, these improvements had not fully taken effect because they had only recently been introduced. We have taken this into account in determining the rating.

Why we inspected: This inspection was carried out following concerns about two notifications.

Follow up: We will ask the provider for an action plan to indicate when they will have consistently addressed all the issues. Please see the ‘action we have

We carried out an unannounced comprehensive inspection of this service on 14 February 2017. After that inspection we received two notifications of incidents following which two people using the service died. As a result we undertook a focused inspection on 21 February 2018 to look at how people were being cared for. This report only covers our findings in relation to the key questions of ‘Safe’, ‘Caring’ and ‘Well-led’. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Hill House Care Home on our website at www.cqc.org.uk

Hill House Care 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.

Hill House Care Home can accommodate up to 23 people with a learning disability, autistic spectrum disorder and physical disabilities. On the day of the inspection, there were 14 permanent people present, one person was visiting their relatives and four people were receiving respite care.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

The service had a manager that had been in post since September 2017. They told us they were in the process of submitting their registered manager application. We will monitor this. 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 systems and processes in place to support staff to act on any safeguarding concerns. Where safeguarding incidents had occurred, the provider had taken appropriate action to investigate these. This included following staff disciplinary procedures.

Staff did not always have sufficient information about risks associated with people’s needs and how these should be managed. Staff had not always adhered to people’s risk assessments as required. Risks to the external environment had not been appropriately assessed or planned for.

Some concerns were identified with the deployment of staff and training gaps were identified in staff training. Safe staff recruitment checks were in place.

Some shortfalls were identified in the management of medicines, the manager had already identified these, and action was being taken to make the required improvements.

Staff were aware of the measures required in the prevention and control of infections and the service was found to be clean.

Staff were kind and caring and had developed positive relationships with people who used the service. Dignity and respect overall was shown towards people.

Independent advocacy information was not available. However, the manager showed knowledge and understanding of the importance of people having access to this information and agreed to provide this. People knew about their care plans and felt involved in discussions and decisions about their care.

The systems and processes in place to monitor quality and safety had not identified all the shortfalls identified during the inspection.

This inspection took place on 14 February 2017 and was unannounced. Hill house provides care for people living with a learning disability. It provides accommodation for up to 35 people who require personal and nursing care. At the time of our inspection there were 23 people living at the home.

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. However, on the day of our inspection the registered manager was unavailable and there were plans to make changes to the management arrangements.

On the day of our inspection staff interacted well with people. People and their relatives told us that they felt safe and well cared for. Staff knew how to keep people safe. The provider had systems and processes in place to keep people safe.

Medicines were administered and managed safely.

The provider acted in accordance with the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The MCA provides the legal framework to assess people’s capacity to make certain decisions, at a certain time. If the location is a care home the Care Quality Commission is required by law to monitor the operation of the DoLS, and to report on what we find.

We found that people’s health care needs were assessed and care planned and delivered to meet those needs. People had access to healthcare professionals such as the district nurse and GP and also specialist professionals. People had their nutritional needs assessed and were supported with their meals to keep them healthy. People had access to drinks and snacks during the day and had choices at mealtimes. Where people had special dietary requirements we saw that these were provided for.

There were sufficient staff to meet people’s needs and staff responded in a timely and appropriate manner to people. Staff were kind and sensitive to people when they were providing support. Staff were provided with training on a variety of subjects to ensure that they had the skills to meet people’s needs. The provider had a training plan in place and staff had received supervision. People were encouraged to enjoy a range of social activities. They were supported to maintain relationships that were important to them.

Staff felt able to raise concerns and issues with management. Relatives were aware of the process for raising concerns and were confident that they would be listened to. Regular audits were carried out and action plans put in place to address any issues which were identified. Accidents and incidents were recorded and investigated. The provider had informed us of notifications. Notifications are events which have happened in the service that the provider is required to tell us about.

We carried out an unannounced focussed inspection of this service on 5 November 2015. A breach of legal requirements was found. After the inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach.

At the last inspection on 5 November 2015 we found that the provider did not have effective systems to ensure that there were sufficient staff available at times during the day to meet people’s needs. At our inspection on 19 April 2016 we found the provider had made the necessary improvements.

People told us that they felt safe at the home. Staff responded to people in a timely manner. There were arrangements in place to ensure that there were sufficient staff to provide safe care.

This inspection took place on 5 November 2015 and was unannounced. Hill House specialises in the care of people who have a learning disability. It provides accommodation for up to 35 people who require personal and nursing care. On the day of our inspection there were 21 people living at the home on a permanent basis and two people who were there for a short break.

At the time of our inspection 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.

There were insufficient staff available at times during the day to meet people’s needs. We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

On the day of our inspection we found that staff interacted well with people. The provider had systems and processes in place to safeguard people and staff knew how to keep people safe.

The provider acted in accordance with the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).If the location is a care home Care Quality Commission is required by law to monitor the operation of the DoLS, and to report on what we find.

We saw that people were involved in making decisions about their care. We found that people’s health care needs were assessed, and care planned and delivered to meet those needs. People had access to other healthcare professionals such as an occupational therapist and GP

Staff were kind and sensitive to people when they were providing support. Staff had a good understanding of the needs of people who lived at the home on a permanent basis. People had access to external leisure activities and excursions to local facilities. However people who remained at the home were not offered activities on the day of inspection.

People had their privacy and dignity considered. Staff were aware of people’s need for privacy and dignity.

People did not have access to regular drinks throughout the day. People were supported to eat enough to keep them healthy. Where people had special dietary requirements we saw that these were provided for.

Staff were provided with training on a variety of subjects to ensure that they had the skills to meet people’s needs. However staff did not feel always feel confident to put their training into practise.

Staff did not always feel able to raise concerns and issues with management. Some staff did not feel part of the overall team. We found relatives were clear about the process for raising concerns and were confident that they would be listened to. People were encouraged to raise issues both formally and informally.

Audits were carried out on a regular basis and action put in place to address any concerns and issues.

The summary is based on our observations during the inspection, speaking with people who used the service, their relatives and the staff who supported them. We also looked at three records and observed care.

We considered the findings of our inspection to answer questions we always ask: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? This is a summary of what we found-

Is the service caring?

We saw how members of staff treated people and observed care. We saw care was delivered well and in a respectful way. We saw staff were kind and attentive and encouraged people to be independent. We saw staff showed patience and gave encouragement when they supported people.

We spoke with a family member who told us, that they felt there was a good staff team who understood their relative's needs.

Is the service responsive?

We saw people's individual physical, mental and social care and support needs were assessed and met. This included people's individual choices and preferences as to how they liked to receive their care.

We observed how staff responded to people in a positive manner and respected their individual preferences. We observed that staff obtained people's consent before they carried out any care. For example, they asked people if they wanted to wear an apron at lunchtime.

Is the service safe?

Risk assessments regarding people's individual activities were carried out and measures were in place to minimise these risks.

The home had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards in place. Mental Capacity Act (2005) and Deprivation of Liberty Safeguards are laws protecting people who are unable to make decisions for themselves. At the time of our inspection no one had deprivation of liberty safeguards in place and no authorisations were in place. We found where people lacked capacity their best interests had been considered.

The service was safe, clean and hygienic. The home had undergone refurbishment in some areas since our last inspection,for example carpets had been replaced.

Is the service effective?

Our observations found that members of staff knew people's individual health and wellbeing needs. There was a process in place to ensure staff were aware of people's changing needs.

We saw that people responded well to the support they received from staff members. We observed that staff responded to people's needs in a timely manner.

Arrangements were in place to ensure people's physical health needs were met. For example, where people had specific issues with their health, such as epilepsy guidance, was in place to support staff to provide effective care.

Is the service well led?

Staff said that they felt supported and trained to safely do their job.

Quality assurance systems were in place and people were listened to.

We reviewed four care plans that showed people’s individual health care needs were addressed.

We had not planned to inspect the general state of the premises on this visit but as we walked around the building we identified a number of concerns. The sluice room door was not able to be closed and locked. One person’s bedroom carpet was badly stained and produced a powerful mal odour.

We reviewed the staff rotas for the week of our inspection, the previous two weeks and the following two weeks. We saw all shifts had been covered.

We saw members of the care staff had gained nationally recognised qualifications in care. This meant that members of staff had the appropriate skills to work in the home and support people’s needs adequately.

We reviewed the home’s system for recording and investigating complaints. Although the home had not received any recent complaints, it had an appropriate way of recording details of subsequent investigations and outcomes.

We carried out this visit in order to establish whether Hill House had addressed a number of concerns we had raised at our last routine inspection in July 2012. In particular we had identified specific concerns about the home’s procedures to reduce the risk of spreading infection, and the maintenance of its premises.

At this visit we found the home had made improvements to its infection control procedures and had introduced a monthly infection control audit carried out by a newly established infection control lead care worker.

We saw the home had carried out improvements to its premises by replacing worn and dirty carpets with new flooring, re-plastering walls and ceilings, and re-decorating each person’s room with colours of their choice.

As part of our inspection we spoke with people who use the service, relatives, the manager, qualified staff member and care workers. People using the service spoke positively about the care and support they received. They told us about the range of activities they were supported to take part in and how staff helped them to develop their daily living skills. One person told us, "I like living here. I can choose what I do, I like going to college" and another person said, “I can look after myself but the staff are there to help me."

During our inspection we observed people who used the service were confident in approaching staff. Staff treated them with respect and patience.

People living in the home, confirmed they felt safe and said they liked the staff who looked after them. One person told us, "Yes I feel safe, the staff are always nice.”

Relatives we spoke with confirmed the carers were respectful towards their family members. They told us they were satisfied with the standards of care and their relatives were happy living at Hill House.