This inspection took place on 26 July 2017 and was unannounced. Hillesden House provides personal care and accommodation for up to 22 older people who may have a dementia diagnosis. At the time of the inspection there were 19 people using the service.

There was a registered manager in post 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.

People had to wait for their care and support as staff were sometimes too busy to respond. Medicines were not stored safely; however people did receive their medicine when they needed it.

People were supported to manage risks to their safety and staff understood how to safeguard people from abuse.

People had support from staff that were knowledgeable and had the skills to meet their needs. People had their rights protected by staff that understood and could apply the principles of the MCA; however this was not always documented in an appropriate way.

People had a choice of food and drinks and received support to ensure their dietary needs were met. People had support to maintain their health.

People received support from staff that were caring in their interactions with people. People were involved in decisions and had their choices observed by staff. People received support in a way that maintained their privacy and dignity.

People had their needs and preferences for care and support met by staff that understood them and they were supported to be engaged in meaningful activities. People understood how to make a complaint and the registered manager had a system in place to investigate and respond to concerns.

There were systems in place to monitor the quality of the service; however these were not always effective in identifying areas which required improvement. People and staff could approach the management team. The registered manager and staff understood their roles and responsibilities.

There was a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 regarding good governance and safe care and treatment. You can see what action we told the provider to take at the back of the full version of the report.

We inspected Hillesden House on June 16 2016. At our previous inspection in June 2014 the provider was not meeting all of the regulations as the building and environment were not safe and did not meet people’s needs. The provider had sent us a report explaining the actions they would take to improve. At this inspection, we found that some improvements had been made since our last visit but further improvements were required to ensure people were safe and their needs were fully met in regards to the environment.

Hillesden House provides personal care for up to 22 people. There were 19 people living at the home at the time of our inspection.

The home is required to have 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 was a registered manager in post at the time of inspection.

Staff understood how to support people to make decisions and when they were unable to do this, support was given; however, the provider did not consistently follow the principles of the Mental Capacity Act 2005 (MCA). This provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

People knew how to complain and staff knew how to respond to complaints. A complaints procedure was in place, and people and their relatives were encouraged to give feedback on the care provided. However, feedback wasn’t always analysed to highlight any issues and to ensure changes were made to improve the quality of the service provided.

There were systems in place to monitor quality of the service; however some of these were not effective in identifying issues of when improvements to the quality of the service were required.

There were sufficient staff to people's needs. We saw that people's needs were responded to promptly and staff had undergone pre-employment checks to ensure they were suitable to work with the people who used the service.

People's risks were assessed and managed to help keep them safe and we saw that care was delivered in line with agreed plans.

People felt safe and staff knew how to protect people from avoidable harm and abuse. Medicines were safely managed, stored and administered to ensure that people got their medicines as prescribed.

Staff were suitably trained to meet people's needs and were supported and supervised in order to effectively deliver care to people. People's health was monitored and access to healthcare professionals was arranged promptly when required.

People were provided with enough food and drink to maintain a healthy diet. People had choices about their food and drinks and were provided with support when required to ensure their nutritional needs were met.

People were supported to maintain good health and had access to healthcare professionals when they needed them. People told us that staff arranged access to healthcare professionals such as the GP promptly when required.

There was a positive atmosphere at the service and people felt the manager was approachable and respectful.

We visited Hillesden House on a planned unannounced inspection, and to follow up on areas of concern identified at and since our last inspection. This meant that the service did not know we were coming.

Below is a summary of our finding based on our observations, speaking to people who used the service and visitors, the staff supporting them and from looking at records. We considered our inspection findings to answer the questions we always ask:-

Is it safe?

Risk assessments were in place where known and potential risks had been identified, with plans of action to inform staff how risks could be minimised.

Improvements to the environment and infection control procedures meant that any risks to people's safety had been reduced.

Staff had received mandatory training and updates.

Is the service effective?

Everyone had a care plan which informed staff how to meet people's needs.

People or their relatives had been involved in the care planning process.

Assessments included people's needs for specialist equipment, mobility aids and dietary requirements.

People's views and audits of the service were undertaken, but arrangements were not yet robust enough to ensure any changes to the service were effective in improving the service.

Is the service caring?

Relatives told us they were happy with the care their relative received. We observed positive interactions and conversations between staff and people who used the service throughout the inspection.

People were treated with dignity and respect.

Is the service responsive?

People's health and care needs were addressed promptly and referral made to relevant health professionals. The provider had acted to address shortfalls in the service following an investigation into an avoidable accident to ensure people were not placed at further risk.

Is the service well led?

Staff had received opportunities to meet as a team and to have supervision of their practice.

Systems were in place to audit the service and monitor the quality of the service.

At the last inspection of Hillesden House we found areas of concern that needed to be addressed and resolved. Following our inspection and publication of the report the provider forwarded an action plan outlining how they intended to make improvements and when they would have achieved them by. This inspection was undertaken to check that the required improvements had been made and people who used the service were no longer at risk.

Most people who used the service were affected by dementia which meant they were not always able to respond to questions because their ability to recall was affected. To ensure we captured the experiences of people we observed what was happening in the home and interactions between staff and people who used the service. We observed that staff showed care and compassion when providing people with support.

At the last inspection the provider was not meeting minimum standards in four areas of care: infection control and cleanliness; safety and suitability of the environment; staffing and supporting staff and in the management and quality monitoring of the service. During this inspection we looked at and checked that the provider had acted to make the improvements they had told us about. We found that some improvements had been made, but further work was needed to ensure that the service was well maintained, cleaned and monitored to ensure that people were safe.

We carried out this inspection as part of our schedule of inspections to check on the care and welfare of people using this service. The inspection was unannounced, this meant the provider did not know we were visiting.

We spoke with five people using the service, a relative, three staff and the manager about how the service was delivered and the quality of service provided. People we spoke with told us, "It’s alright here" and "They (the staff) are good to us".

Some people were not able to communicate well with us because dementia affected their ability to do so. For a period of time we observed the routines, staff interactions and activities within the home. We observed that staff were compassionate to people’s needs and respected decisions that they made, including how they wanted to spend their time, and what they had to eat.

We checked to see if the provider had systems in place to manage and reduce risks associated with; infection control, the environment and fire safety. We found significant concerns in these areas and referred our concerns to the relevant agencies. The lack of action by the provider meant that people were at risk of harm.

The provider was not able to demonstrate that staff were provided with regular opportunities to meet or to review their practice. Some training was not overseen by a competent person. This meant people may be at risk because staff were not monitored regularly to ensure their practice was safe.

We carried out this inspection as part of our planned schedule of visits. The inspection was unannounced which means the service did not know we were going to visit.

We spoke with four people who used the service, three staff and a relative. People we spoke with told us, "I'm happy here, the staff are great nothing is too much trouble." A relative said, "We have been satisifed with the care our relative received. The staff tell us what is happening and we are involved in care plan reviews."

Through a process called 'pathway tracking' we looked at care plans, to establish the care people required and if it was being delivered according to the individuals wishes. This helped us establish that people were getting appropriate care that met their needs and supported their rights.

The service had systems in place to ensure that staff understood their responsibilities in safeguarding (protecting vulnerable adults) and reported concerns appropriately.

Systems were in place to ensure people’s medication was managed and recorded appropriately.

Observation of the environment showed that maintenance and repairs were not always being completed speedily, to ensure people's safety.

We spoke to staff and looked at the training and support available. Staff told us they were supported and had the opportunity to meet with the manager regularly.

During the inspection we looked at the process the service had in place to monitor the quality of the service provided. We found systems were in place for auditing and monitoring the service.