Hill Top Lodge is registered to accommodate and deliver nursing and personal care to a maximum of 85 people. People who live there have health issues related to old age and/or dementia. At the time of our inspection 47 people were living there. The home has three units’ within the premises; these are called Willow (ground floor) Lavender (middle floor) and Bluebell (top floor). Bluebell unit was temporarily not in use as some decisions were being made about its future use, whilst restructuring and redecoration was also on-going.

Our inspection was unannounced and took place on the 8 December 2016. At our last inspection in October 2015 the provider had not breached the regulations of the Health and Social Care Act but we identified that some areas in the key questions of safe, effective and responsive required improvement. We found on this our most recent inspection the provider had made the necessary improvements.

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.

People were protected and kept safe by staff who understood their roles and responsibilities in relation to protecting them from abuse and avoidable harm. Potential risks that staff needed to be aware of when supporting people were clearly outlined, regularly reviewed and updated appropriately. Sufficient levels of staff were made available to meet people’s needs in a timely manner. Effective recruitment procedures were operated by the provider. Sufficient quantities of people’s medicines were available and these were stored, disposed of and administered effectively.

Staff had access to a range of training to provide them with the level of skills and knowledge to deliver care to people safely and efficiently. The provider ensured that all new staff were provided with an induction before fully commencing in their role and regular supervision to discuss their performance and development needs. People’s human rights were respected by staff who worked within the principles of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.

Staff were knowledgeable about how to support people to maintain good health and accessed professional healthcare support for people when necessary. When concerns were raised about people’s level of food or fluid intake this was monitored closely and any additional professional advice and/or input was sought.

Staff readily offered people the reassurance or emotional support they needed. People were involved in any decision making about their care. Staff interacted with people in a positive manner and used encouraging language whilst maintaining their privacy and dignity when supporting them. People were supported to maintain relationships with their families and able to have visitors at any time, without restriction.

People were involved in the assessment of needs and planning of care. Staff demonstrated they knew and understood people’s preferences, likes and wishes. People’s cultural and spiritual needs were considered and planned for accordingly. The provider acknowledged, investigated and responded to complaints in a timely manner and in accordance with their own policy.

The home had a relaxed atmosphere throughout, where people appeared content and comfortable in staff company. An open and inclusive culture was evident within the service, which was encouraged by the registered manager. Staff benefited from access to supervision, meetings and a regular consistent staff team. People were actively encouraged to give their thoughts, suggestions and opinions about the service. Staff were well informed, kept up to date and were regularly consulted about plans for the development of the service. Re

This unannounced inspection took place on 13 October 2015.

At our last inspection in March 2015, we found that the provider was not meeting four of the regulations associated with the Health and Social Care Act 2008 which related to; the care and welfare of people who use services, the management of medicines, assessing and monitoring the quality of service provision and staffing. Following the inspection we asked the provider to take action to make improvements. The provider sent us an action plan outlining the actions they had taken to make the improvements. During this inspection we looked to see if these improvements had been made and found that they had been.

Hill Top Lodge is registered to accommodate and deliver nursing and personal care to a maximum of 85 people. The majority of people who live there were living with dementia or an associated need. The home has three units’ within the premises; these were called Willow (ground floor) Lavender (middle floor) and Bluebell (top floor). Recent temporary closure of Bluebell unit meant that the service was only able to accommodate 51 people. At the time of our inspection 46 people were living there.

There was no registered manager in post, but the provider’s operations manager was acting as manager at the time of our inspection. A manager had been recruited for the service and had commenced their post the day before 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.

We found that overall medicines administration within the service was safe. The provider needed to provide more detailed guidance for staff in relation to ‘as required’ medicines and ensure that staff followed instructions available in relation to administering medicines within food or drinks.

There were systems in place to protect people from abuse and harm. Staff had a clear knowledge of how to protect people and understood their responsibilities for reporting any incidents, accidents or issues of concern.

The provider had a suitable number of staff on duty with the skills, experience and training in order to meet people’s needs. People using the service, their relatives and staff were satisfied that there were enough staff available within the service.

Staff had access to a range of training to provide them with the level of skills and knowledge to deliver care safely and efficiently. Staff had the opportunity to undertake training in addition to the standard level of training to develop their skills.

Staff were able to give an account of what a Deprivation of Liberties Safeguard (DoLS) meant for people subject to them and described how they complied with the terms of the authorisation when supporting that person.

Mealtimes were not structured in a way that encouraged people to identify it as a social event or an opportunity to interact with others. We found the ground floor environment was not conducive for supporting people with dementia and did not promote people’s independence.

Staff were responsive to people when they needed assistance. Staff interacted with people in a positive manner and used encouraging language whilst maintaining their privacy and dignity.

Records contained little information regarding people’s past life history and the staff we spoke with lacked any detailed knowledge about people’s personal history, for example their career or family history.

People and their relatives told us they were provided with the information about the service and their care and treatment. People were supported to maintain their religion.

Information was on display about how to make a complaint. The provider demonstrated to us how they had effectively investigated complaints that they had received.

Little account had been taken of people’s individual preferences or previous interests when planning activities. People, their relatives and stakeholders were asked to provide feedback about the service through questionnaires and meetings.

People, their relatives and staff spoke confidently about the leadership skills of the acting manager. Structures for supervision allowing staff to understand their roles and responsibilities were in place.

The acting manager undertook regular checks on the quality and safety of the service.

The provider is registered to accommodate and deliver nursing and personal care to a maximum of 85 people who may have dementia or an associated need. At the time of our inspection 67 people were living there.

This focussed inspection was unannounced and took place on 10 March 2015.

Care and support was provided from three units within the premises these were called Willow (ground floor) Lavender (middle floor) and Bluebell (top floor).

Our previous inspections found that there were breaches and/or repeated breaches of the law from 2012 to present. The issues relating to the breaches continued to place people at risk of accidents and incidents due to insufficient staffing levels, insufficient action to ensure people’s welfare and safety, needs not being consistently met and unsafe medicine practices. In the summer of 2014 the local authority told the provider that they must restrict new admissions to the home until improvements had been made.

Following our last inspection of 7 August 2014 the provider sent us an action plan to tell us what they would do to meet the legal requirements concerning the breaches. We undertook this focused inspection to check that they had followed their action plan. We found that improvements had been made in some areas but in others breaches continued.

A manager was not registered with us as is required by law. 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.

We found that medicines were not being managed safely or to ensure that people received their medicine as it had been prescribed by their doctor.

We found that staffing levels were not always adequate to meet people’s needs and prevent the risk of them sustaining injury.

Staff did not support people with their hydration needs. We found that staff did not offer people a drink when they got up in the morning or sufficient fluids throughout the day to meet their care and health needs.

We found that the monitoring processes the provider had in place were not effective to make improvements to prevent breaches and repeated breaches of the law. Monitoring systems had not been effective to prevent people being placed at risk of injury or their needs not being met.

The provider had taken some action to comply with the requirements of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). This better ensured that people received care in line with their best interests and were not unlawfully restricted.

The provider had taken action to ensure that equipment was safer to use and had reduced the risk of scalding from excessive hot water temperatures.

This report only covers our findings in relation to our following up of the previous breaches. You can read the report from our last comprehensive inspection by selecting the all reports link for Hill Top Lodge on our website at www.cqc.org.uk.

You can see what action we told the provider to take at the back of this report.

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service.

Hill Top Lodge was last inspected on 3 September 2013 where we found a shortfall in the number of staff so that people’s needs were not always met. During this inspection we saw that although some actions had been taken there was still a shortfall in the number of staff. This inspection was unannounced which means that no one at the home knew we were going to inspect the home.

Hill Top Lodge provides nursing and personal care to up to 85 people. Accommodation is provided over three floors and there are adaptations in place to ensure that the needs of people with restricted mobility can be met. The home provides single bedrooms, lounges, dining rooms, bathing facilities and a small enclosed garden. At the time of our inspection there were 72 people living in the home.

There was no registered manager in post at the time of our inspection but an acting manager had been appointed. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

We saw that people living in the home were not always protected from harm. Medicines were stored safely but arrangements were not fully in place to check that people were given their medicines as prescribed or on the days instructed by the prescriber. This meant that sometimes people had not received regular pain relief because pain relief patches had not been changed at the required intervals. Medicine administration records (MARs) were not always completed so that it was not clear that people had received their medicines or if not, why not. We saw that there was not always sufficient information for staff to give ‘as and when required’ medicines in a consistent and safe way.

We saw that people were not always protected from the risks of injury because safe moving and handling procedures were not followed. For example, we saw a wheelchair used without foot plates. This could result in injury to people’s feet. Staff told us that foot plates should have been used.

We saw that equipment was not always adequately risk assessed and plans were not put in place to prevent people from being injured. For example there was a risk of scalding from hot water.

A new manager had been appointed but they had not been in post long enough to be registered with us. There were systems in place to monitor and improve the service; however, we saw that the systems in place had not ensured that people were safe. This meant that the provider was not meeting the requirements of the law in respect of medicines management, care and welfare of people, maintaining equipment and monitoring the quality of the service. You can see what actions we have asked the provider to take at the back of the report.

People told us and we saw that there were not always sufficient staff available to ensure that people’s needs were met consistently. We saw that people had to wait to be assisted with their meals and for people to have social interactions so their emotional and social needs were met.

We saw that the manager was aware of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and applications for safeguards had been made for some people that required them but not all. It was not always clear that decisions made on behalf of people and actions taken in respect of their care were always in their best interests.

People or their relatives were involved in identifying people’s needs so that staff had the information they needed to support them properly. Staff received training and supervision so that people were supported by staff that had the skills and knowledge to meet people’s needs. We saw that people’s dietary needs were met and people were supported to have their health needs met. However, we saw that people did not always know that they could ask for drinks throughout the day so did not always receive drinks when they wanted them.

People told us they were happy with the care they received and we saw that people were well cared for and individual differences respected and supported. People were supported to look well groomed and their privacy and dignity promoted. People were supported to maintain links with people who were important to them. This meant that people received support in a caring and compassionate way.

We saw that staff was caring and responded to people’s distress in a kind and caring way but some people were not able to summon assistance quickly and safely because call bells were not accessible to them. There were activities to occupy some people but not sufficient to meet most people’s needs especially people with dementia or those that spent most of their time in their bedrooms.

During our inspection of this service in April 2013 we found noncompliance with five essential outcome areas. The noncompliance included the areas of, care and welfare, nutrition and meal time experiences, safeguarding, staffing levels and attitudes and the quality monitoring of the service. We carried out this inspection to find out if improvements had been made and found that in most areas they had with the exception of staffing levels. All of the staff we spoke with told us in their view improvements had been made. One staff member said, “Things are much more organised now”.

During our inspection we spoke with people who lived at the home, staff, management and relatives. As during our previous inspection, people who lived there told us positive things about their experiences of living at the home, for example, “I like it here”, and, “The staff are kind.” Relatives told us that they were happy with the care provided. One relative said, “They have improved since they came in here”.

We found that care relating to dementia needs had improved. We observed some good interactions between staff and people living at the home. Our observations showed that the care provided now was much more person centred.

We saw that meal planning and the support provided at meal times was adequate. Changes had been made to meal times which the people who lived there preferred. Generally we observed that people got the support they needed to eat and drink.

We found that the previous high number of occurrences of aggression between people who lived at the home had decreased. We found that updated care planning systems and the more frequent staff interactions with people promoted positive behaviour which had reduced the incidents of aggression.

Although we identified that staff attitude and performance had improved significantly, we found that further improvement was needed regarding staffing levels and staff retention.

We found that improved monitoring processes were adequate to assure people that they would receive a good, safe, service.

During our inspection we spoke with people living at the home, staff, management and relatives. A number of people told us positive things about their experiences of living at the home, for example, “I have lived here for years and think it is nice”, and, “The staff are kind.” However, the majority of people, staff and management confirmed that overall improvements were needed so that people could be assured that their needs would be met.

We found that care relating to dementia needs was inadequate. We observed poor interaction between some staff and people living at the home. Our observations showed that the care provided was ‘task’ orientated rather than being person centred.

We saw that meal planning and the support provided at meal times was inadequate. A number of people told us that they would prefer that the breakfast time was earlier and we observed that people did not get the support they needed to eat and drink.

We identified that there was a high number of occurrences of aggression between people who lived at the home. We found that care planning and staff interaction did not always promote positive behaviour.

A number of people told us that there was not enough staff especially at night. We saw that a number of staff lacked the knowledge and experience of how to care for people with dementia.

We found that monitoring processes, management and direction had not been adequate to assure people that they would receive a good, safe, service.

The reason for this inspection was to look at the safe handling of medicines as we were told that there were concerns. This was assessed by a pharmacist inspector. We looked at the storage of medicines, medicine administration records and some care plans.

We spoke with seven members of staff and one person living in the service who told us ‘’I am happy here. They are all lovely’’.

There were 71 people living at the home on the day of our inspection visit. No one knew we would be visiting. We spoke with six people who lived at the home, six members of staff, three visitors and the new manager.

Some of the people living at this home had dementia care needs. As people with dementia are not always able to tell us about their experiences, we used a formal way to observe people during this inspection visit to help us understand their experiences better. We call this a Short Observational Framework for Inspection (SOFI). We spent two hours in two communal areas, observed a total of seven people and recorded their experiences at regular intervals. This included people’s state of well being, how they interacted with staff members and other people who lived at the home and the environment.

We found that the atmosphere of the home was relaxed and friendly. Our observations showed that people were at ease with the staff. We saw that staff treated people with respect and dignity and understood how to communicate with them. People told us and we saw that choices were offered and that people’s views were sought and taken into consideration.

Staff received a range of training which included dementia care training, so that they had up to date knowledge and skills in order to support the people who lived at the home.

Staff we spoke with were able to tell us about people’s needs so that they received care in a way that they preferred. A visitor told us that their relative was being very well looked after. They said “ Everything that should be done for them is being done”. A person living at the home told us " I am so grateful for this place. They have looked after me so well. If I had not come here I am sure I would be dead by now. It is wonderful”.

The provision of activities had improved and had been developed since our last inspection of January 2012. A range of individual and group activities were offered so that people had the opportunity to take part in activities that they enjoyed. During our inspection a person was taken out into the community. When they returned they told us” I really, really enjoyed that. It was so good to get out and do a bit of shopping myself”.

We sampled the files for three new members of staff. We found that recruitment checking processes were robust and thorough which meant that unsuitable staff were less likely to be appointed and people were at less risk of harm.

There were systems in place to monitor how the home was run, to ensure people received a quality service. We found that positive changes had been made since the appointment of the new manager. The manager had listened to people living at the home, their relatives and funding authorities and had made changes accordingly.

We carried out this inspection as a number of concerns had been raised by external contractors and professionals. These included the lack of appropriate action being taken when a person stopped breathing and a serious fall. Hill Top Lodge management had also notified us about a number of incidents that had occurred.

Due to concerns the ‘host authority’ Sandwell has suspended placements at Hill Top Lodge. This suspension was still in place at the time of our inspection. As a result of this there are a number of vacancies. The location is registered to provide accommodation and nursing and personal care to a maximum of 85 people. There were 68 people living at the location at the time of our inspection.

The premises consist of three floors. The ground and first floors provide care to people who have a range of diagnoses which may include dementia but do not have nursing needs. The second floor provides care to people who have a range of diagnoses which may include nursing needs.

We arrived at Hill Top Lodge at 08.30 hours so that we could indirectly/ directly observe or sample routines and care delivery from early morning. During our inspection we spoke with staff, managers and some external professionals.

During our inspection we spoke with four people living at Hill Top Lodge below, are a few examples of what they said to us;

“It’s a good place. They take care of us”.

“I like it here”.

“The staff are kind”.

We spoke with two relatives. They were complimentary about the care provided. One relative told us; “We are happy with the care, no complaints. The staff are very good, they are kind and caring. We are always kept informed if there are any changes or problems”.

Although people made positive comments about Hill Top Lodge in general and the service they received, our inspection findings showed that some improvements are needed to make sure that people are safe. These improvements include; activity provision and stimulation, a greater prevention of falls and better measures to make sure that bed rail usage is safe.