The inspection took place on 21 November and was unannounced.

Hillsborough House provides accommodation and personal care for up to 14 people with a learning disability. The home is a large converted villa in a residential area of Keynsham. The accommodation is set out over three floors which are accessed via stairs to the front and back of the house. At the time of our inspection there were 12 people living at the home.

The house had a kitchen, dining area, two lounges, an office and a staff sleeping room. Each person had their own bedroom and shared bathrooms.

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 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.

At our last inspection in November 2017 we rated the service requires improvement and identified a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to good governance. At this inspection we found improvements had been made.

At this inspection the service has been rated good.

Improvements and changes had been made in staffing deployment, medicine guidance and care records. Staff were supported through an effective induction, regular supervision and training. There were opportunities for additional training specific to the needs of the service, including the care of people with epilepsy and autism.

Care records were not used consistently to ensure staff had easy access to important information that supported continuity of care. We have made a recommendation about this.

Emergency procedures were in place in the event of fire and people knew what to do, as did the staff.

People said the staff made them feel safe because they were kind and reliable. However, some improvements were required. Potential risks to people's health and wellbeing were not uniformly documented to ensure consistency in standard and quality of care plan reviews. Initial assessment care plans were not documented on the provider’s documentation. This meant the quality of the assessment of people's care needs was variable or did not routinely take place before the service began.

People enjoyed participating and achieving individual goals that were inclusive and personal to them. People received care that improved their health, wellbeing, independence and that enabled them to gain new skills and access their local community.

Medicines were managed safely and in accordance with current regulations and guidance. There were systems in place to ensure that medicines had been stored, administered, audited and reviewed appropriately. Where errors had occurred, there was a protocol for staff to follow to minimise risk of harm.

People were happy and relaxed with staff and there were sufficient staff to support them. When staff were recruited, their employment history was checked and references obtained. Checks were also undertaken to ensure new staff were safe to work within the care sector.

Staff were knowledgeable and trained in safeguarding adults and what action they should take if they suspected abuse was taking place. Staff had a good understanding of equality, diversity and human rights.

People were being supported to make decisions in their best interests. Consent to care and treatment was sought in line with the Mental Capacity Act 2005. Capacity assessments were untaken where appropriate and decisions taken in people's best interest were decisi

We undertook an unannounced inspection of Hillsborough House on 3 October 2017. When the service was last inspected in May 2016 five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were identified.

During this inspection we checked that the provider was meeting the legal requirements of the regulations they had breached. You can read the report from our last comprehensive inspection, by selecting the 'All reports' link for Hillsborough House, on our website at www.cqc.org.uk

Hillsborough House provides personal care and accommodation for up to 14 people with learning disabilities. At the time of our inspection there were 14 people living at the home.

A registered manager was 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 home is run.

At this inspection we found that improvements had been made within the service. Four of the five previous breaches had now been met. We found that the service was not always responsive to people needs as further improvements were required in regards to daily information recording and guidance for agency staff. We have made a recommendation in regards to people’s fluid and nutrition.

Systems to monitor and review the quality of care did not always identify potential risks to people. Systems were in place to gain feedback from people, relatives and staff. This was through meetings and surveys. However, the information collected through surveys was not always utilised to make changes or improvements.

Improvements and changes had been made in staffing deployment, medicine guidance and person centred information in care records. Staff were supported through an effective induction, regular training and supervision.

Safe recruitment procedures were in place. People were involved in the interviewing and selection of new staff members. The service was compliant with the requirements of the Deprivation of Liberty Safeguards. Consent to care and treatment was sought in line with the Mental Capacity Act (MCA) 2005. Capacity assessments were untaken where appropriate and decisions taken in people’s best interest were decision specific.

The service was clean and maintenance untaken where required. Further improvements to the environment and garden had been identified. Incidents and accidents were recorded. Actions taken in response had not always been clearly documented.

People were supported by staff who were kind, caring and respectful. Staff knew people well and how people preferred to be supported. People independence was promoted and encouraged. People were supported with their healthcare needs. Recommendations from professionals were followed.

Communication systems with staff and health professionals had improved. People were involved in activities of their choice.

We found one 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 this report.

We carried out a comprehensive inspection of Hillsborough House in January 2015. Four breaches of the legal requirements were found at that time. After the inspection, the provider wrote to us to say what they would do to meet the legal requirements in relation to these breaches. The breaches related to the management of medicines, staffing, care records and protecting people from abuse.

Following the inspection the provider wrote to us to say what they would do to meet the legal requirements. We undertook a focused inspection on 13 August 2015 to check the provider had followed their plan and to confirm they now met the legal requirements. We found that sufficient action had been taken to achieve compliance in the regulations previously breached.

You can read the report for previous inspections, by selecting the 'All reports' link for ' Hillsborough House' on our website at www.cqc.org.uk

This inspection took place on 11 and 12 May 2016 and was unannounced. Hillsborough House is a care home service without nursing for up to 14 people with physical and learning disabilities. On the day of our inspection there were 11 people living at the service.

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.

At this inspection we found that the provider had failed to sustain improvement following the last inspection of the service. A number of the shortfalls at this inspection related to matters which had been brought to the provider’s attention on previous occasions by the Commission.

The systems in place for monitoring quality and safety were not sufficient to ensure that the risks to people were identified and managed.

The provider’s quality assurance systems to monitor records made by staff or records that related to the management of the service were ineffective.

There were not sufficient numbers of staff to support people safely. We had feedback from staff and people that the current staffing arrangements did not meet the needs of people using the service.

The provider had failed to protect people from the risk of abuse; they had not formulated a plan to prevent safeguarding incidents.

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

Staff supervisions were not undertaken as planned; there was a failure to monitor and feedback on staff performance. Staff training was not up to date.

The home was not suitably clean.

There were suitable arrangements in place for the safe storage, receipt and administration of people’s medicines. However protocols for PRN (as required) medicines and topical medicines were not in place.

Staff respected people’s privacy and we saw staff working with people in a kind and compassionate way responding to their needs.

Deprivation of Liberty Safeguards (DoLS) applications had been made for those people that required them. 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. The staff did not have a clear knowledge of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

Meetings had been arranged in order to enable people’s best interest to be assessed when it had been identified that they lacked the capacity to consent to their care and treatment.

People were supported by the staff to use the local community facilities and had been supported to develop skills which promoted their independenc

We carried out a comprehensive inspection of Hillsborough House in January 2015. Four breaches of the legal requirements were found at that time. After the inspection, the provider wrote to us to say what they would do to meet the legal requirements in relation to these breaches. The breaches related to the management of medicines, staffing, care records and protecting people from abuse. 

We undertook a focused inspection on 13 August 2015 to check the provider had followed their plan and to confirm they now met the legal requirements. This report only covers our findings in relation to these areas. You can read the report from our last comprehensive inspection by selecting the 'All reports' link for ‘Hillsborough House’ on our website at www.cqc.org.uk

Hillsborough House is a care home without nursing for up to 14 people with learning disabilities. There were 13 people living at the home at the time of our inspection.

The home was without a registered manager at the time of this 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. A manager was in post and this person had submitted an application to be registered with the Commission.

At our inspection on 13 August 2015 we found that the provider had taken action in order to meet the legal requirements.

Action had been taken to ensure people’s medicines were being managed in a safe way. There had also been changes in the deployment of staff. As a result, people had more support from staff with their individual activities and staff were better able to ensure people were safe.

People regularly talked to staff about their support and to discuss any changes that were needed. Improvements had been made to the care records so there was better information for staff about people’s current needs and the changes that had been made.

Twelve people lived in the home on the day of our inspection. One person was on holiday and another person was in hospital. The registered manager was on training, so we met with a senior person in charge.

We were given a tour of the home and the grounds. We spoke with three people who lived in the home. They told us they liked living at the home and staff were nice. We spoke with a senior member of staff and four members of staff. We read the care records of three people who lived in the home. We inspected the policies and procedures, the record of complaints and the safeguarding folder which included details of safeguarding referrals and the audit for 2013. We read the reports from quality monitoring visits. We observed staffs interactions with people they were supporting.

A single adult social care inspector carried out the inspection. The focus of the inspection was to answer five questions: Is the service safe, effective, caring, responsive and well-led?

We found the service was safe.

Staff told us they had received training about safeguarding vulnerable people. They told us they would report concerns immediately to a senior staff member. Policies, procedures and local guidelines were available for staff to follow.

We saw that staff had a good rapport and interacted well with the people living in the home. This included our observation of people confidently and freely approaching members of staff when they wanted support.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS), which applies to care homes. The provider had policies and procedures in relation to the Mental Capacity Act (MCA). Applications had been submitted for DoLS authorisations where applicable but none had yet been authorised. This was in line with the provider's policies and procedures, and the CQC would be notified as required by law. This meant that people would be safeguarded as required. We saw systems in place to ensure that managers and staff learnt from accidents and incidents as well as comments received from people who used the service and their relatives.

We found the service was effective.

People's health and care needs were assessed and we found they had been supported to be involved with their health action plans and care plans. We saw involvement from external health professionals such as the community learning disability team (CLDT).

We spoke with staff who told us that the induction training for their role had been thorough. They also told us they received regular supervision. The records we reviewed did not identify annual appraisals which was confirmed by a senior member of staff.

We found the service was caring.

We spoke with staff, and observed the interactions they had with people. People told us they liked staff and we found, without exception, that staff spoke kindly and demonstrated a good understanding of people's needs. Staff said they "loved working with the people" and that the home had a "very friendly, family atmosphere." During our visit we observed there was a relaxed atmosphere with people choosing where they wished to spend their time. We observed staff treating people with kindness and patience. Staff demonstrated they knew people's needs and ensured people were treated with privacy and dignity.

We saw people freely expressing what they wanted to do during the day, and they were supported by kind and reassuring staff.

We found the service was responsive.

People had their needs assessed on a regular basis. They met with their key workers regularly to review their plans and to discuss what was important to them. However, we found care plans had not always been updated to show people’s actual care and treatment needs.

Staff told us that people understood what they said and were able to respond through various means which included the use of symbols, signs and gestures.

We found the service was well-led.

We saw that people were asked for their feedback. We saw the responses from people and found there were many positive responses and some suggestions for improvements. People said they liked their home and did not want to change anything. Suggestions for improvements included more day trips and access to the home's vehicle. We saw evidence of an activities board which incorporated days out and the use of the home's vehicle. Feedback was recorded in people's meetings and we saw a letter sent to families in response to their feedback. The audit of people's feedback provided a summary of responses but did not include an action for each item.

The service had a good quality monitoring system which ensured that the manager was aware of any changes in the service and was able to respond proactively. We observed good relationship between staff and people on the day of our visit. Staff were clear about their roles and responsibilities and told us that they were supported by their manager.

We looked at two standards concerning the upkeep and cleanliness of the premises which were not being met when we last inspected the home in January 2013. We found that improvements had been made in these areas. The kitchen and the bathrooms had been refurbished so that they were more hygienic and nicer areas for people to use. People told us that they liked the rooms being cleaner and they were pleased with the work that had been carried out.

We also looked at the arrangements being made for supporting people with their medicines and with their health and personal care. Suitable arrangements were being made for meeting people’s needs in these areas.

We found that people’s needs were being kept under review through meetings and the involvement of key workers. One person who used the service said that they had a ‘lovely key worker’ who talked to them about their needs and how they were getting on. We saw that staff were observant of changes in people’s health and personal care needs, which helped to ensure that people received the right level of support.

At the time of our inspection there were 13 people living in the home. We spoke with seven people who used the service and three members of staff.

The people we spoke with were able to tell us about their experience of living in the home and overall the comments were positive.

Some people’s comments included; “it’s brilliant here”, “the staff are nice to us, I make things”. One person told us that they were supported to go horse riding and was very positive about the experience. Another person told us “the staff now are fantastic, but the house is falling down”. We spoke with this person in depth about their comments. They told us the decorating needed attention around the home, but the care from the staff was “the best ever”.

People were observed engaging with staff in a relaxed manner and some people were negotiating what to do for the rest of the day. For example, one person was heard deciding with staff to go out shopping and what to buy.

People living in the home were encouraged to be as independent as possible and were observed making their own hot drinks, as and when required in a small area of the dining room.

Throughout our visit we observed people being enabled to make choices of what to do and what to eat. People we spoke with confirmed all the choices and involvement they had in their daily lives.

We spoke with five people who lived at Hillsborough House who gave us positive comments on their experience of living at the home. They told us about the choices that they had and what they enjoyed doing such as "I can choose to go to go out and where I go on holiday" and "I can choose my food". Others told us "It’s nice here".

One person told us that they had been on holiday with their family They also told us "I speak to my Mum often".

We asked people who used the service if they felt safe living at Hillsborough House and they told us that they did. One person told us "If I was worried I would speak to my staff".

We found that people we spoke with knew staff well and had built up a good relationship with them. Telling us "I have been out to dinner and we go shopping to buy clothes”.

During our visit people were seen to be coming and going with staff. One person told us that they had been to the shops and another had been to college.

Two people that used the service showed us their bedrooms and told us that they had chosen the colours and bedding. The rooms were personalised and reflected their hobbies and interests.

Care plans contained details of the needs of people living at the home. People had access to healthcare professionals such as GP's and dentists.

The service had a quality assurance system in place which involved seeking the views of people living at the home and their families.

We carried out an unannounced inspection of Hillsborough House on 28 and 29 January 2018. At the last inspection we found there were breaches of legal requirements for Care and Welfare Regulation 9. The provider said they would take action to address the concerns by 31 December 2014.  However, we found at this inspection there was still a breach of this regulation.

Hillsborough House provides care and accommodation for up for 14 people with learning disabilities.

A registered manager was 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.

People told us they felt safe and gave us examples on how this was achieved but the they felt “frightened” when other people used aggression and violence to show their frustrations. Staff told us their presence was not always possible to prevent incidents of physical abuse. People were not safeguarded from abuse or the risk of abuse because there were not enough staff available to provide the support people needed.

People were not protected from unsafe medicine systems. Parts of the property were dirty and fridge and freezers were not maintained at a safe temperature.

People told us the staff were kind and they knew how to care for them. The induction for new staff prepared them for the role they were to perform. Essential training ensured staff had the skills needed to meet people’s need. Staff told us vocational qualifications and specific training to meet people’s changing needs was not available to all staff because of limited places.

Mental Capacity Act 2005 (MCA) assessments were undertaken to assess people’s capacity to make decisions about their accommodation and about leaving the property without staff supervision. Where people lacked capacity to make these decisions Deprivation of Liberty Safeguards (DOLS) were made to the supervisory body. However, for some people the MCA assessments were not accurately completed. This meant the restrictions in place were not based on the person’s ability to make decisions.

People participated in meal preparation and prepared their refreshments. We saw staff use a variety of approaches to encourage people to become independent. People told us their privacy was respected but we saw institutional practices. The

regimes introduced to prevent inappropriate behaviours such as the misuse of bathroom toiletries were imposed on people. Individual strategies were not developed to prevent this behaviour from happening. This meant people’s dignity was not respected.

Staff told us the manager was approachable and the staff worked well as a team. They told us there was a person centred approach to care which meant people were treated as individuals.

We found several breaches 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 the report.