This inspection was carried out on the 23 August 2017 and was unannounced. Hydon Hill provides long-term nursing care and short stay care for up to 46 people with physical disabilities and nursing needs. The service offers specialist support for those who have experienced a brain injury. At the time of our inspection 39 people were living at the service.

There was a registered manager in post on the day of the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 sufficient numbers of staff deployed at the service to meet people's needs and people received care when they needed. People and staff felt there were enough staff. People told us they felt safe at the service and staff had a good understanding about the signs of abuse. Staff were aware of what to do if they suspected abuse was taking place. There were systems and processes in place to protect people from potential risks and people felt their risks were well managed.

Recruitment practices were robust and relevant checks had been completed before staff started work. Nurse’s professional registration was kept up to date. Medicines were managed, stored and disposed of safely. Any changes to people's medicines were prescribed by the person's GP and administered appropriately.

Fire safety arrangements and risk assessments for the environment were in place to help keep people safe. Staff understood what they needed to do in an emergency. The service had a business contingency plan that identified how the service would function in the event of an emergency.

Staff had received appropriate supervision with their managers including clinical supervision. The staff team were knowledgeable about people's care needs. People told us they felt supported and staff knew what they were doing and that the training they received was effective.

Staff were up to date with current guidance to support people to make decisions. Where people had restrictions placed on them these were done in their best interests using appropriate safeguards. Staff had a clear understanding of Deprivation of Liberty Safeguards (DoLS) and the Mental Capacity Act (MCA) as well as their responsibilities in respect of this. MCA assessments took place decisions where appropriate were made in people’s best interests.

People had sufficient amount to eat and drink and there were arrangements in place to identify and support people who were nutritionally at risk. People told us that they enjoyed the food at the service. People were supported to have access to healthcare services and were involved in the regular monitoring of their health. The provider worked effectively with healthcare professionals and was pro-active in referring people for assessment or treatment.

Staff involved and treated people with compassion, kindness, dignity and respect. We saw staff treat people in a caring way. People's preferences, likes and dislikes had been taken into consideration and support was provided in accordance with people's wishes. People's privacy and dignity were respected and promoted when personal care was undertaken. People told us that staff treated them well and that they were caring.

People's needs were assessed when they entered the service and on a continuous basis to reflect changes in their needs. Care plans were detailed and provided staff with guidance on how to provide the most appropriate care.

People were encouraged to voice their concerns or complaints about the service. Concerns were used as an opportunity to learn and improve the service.

People had access to activities that were important and relevant to them. There were a range of activities available within the service and outs

This unannounced inspection was carried out on 5 August 2016. Hydon Hill is a care home providing both residential and nursing care to people with physical disabilities and nursing needs. The service is currently registered to accommodate up to 46 people. On the day of our inspection 35 people lived in the service.

There was a registered manager in post on the day of the 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.

During our last inspection on 9 and 10 November 2015 we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The overall rating for this service was rated as 'Inadequate'. We carried out this inspection to establish whether the requirements were being met. On this inspection sufficient improvements had been made to meet the Regulations and therefore the service is no longer in ‘Special measures.’ Where key questions have been previously rated as inadequate we expect any improvements to have been sustained over a period of time. Due to the length of time since the last inspection, although improvements have been made we have been unable to show that the service will maintain these. This is why Safe and Well-led have been rated as requires improvement.

People said that they felt safe. One person said, “I use my emergency bell and I know staff will come.” There were enough staff deployed around the service to ensure that people’s needs were being met. Staff had knowledge of safeguarding adults procedures and what to do in the event of abuse occurring.

Risk assessment guidance for people was detailed and being followed by staff. Appropriate checks were undertaken on staff before they started work. In the event of an emergency, such as the building being flooded or a fire, there was a service contingency plan which detailed what staff needed to do to protect people and make them safe.

Medicines were stored appropriately and audits of all medicines took place. Medicines Administrations Records (MARs) charts for people were signed for appropriately and all medicine was administered, stored and disposed of safely by staff who were trained to do so.

People’s rights were met under the Mental Capacity Act 2005 (MCA). Assessments had been completed specific to the decision that needed to be made. DoLS applications had been submitted to the local authority and were supported by the appropriate mental capacity assessments.

People received care from staff who had received appropriate training and supervisions and appraisals for staff had been undertaken.

People said that they enjoyed the food at the service. People at risk of dehydration and malnutrition had their needs met and people were supported to remain healthy.

Staff treated with people with kindness and compassion. One person said, “The staff really care and they are patient with me”. People were treated with dignity and respect and staff were attentive to people and anticipated their needs. People were involved in the planning of their care and care was provided with around people’s preferences.

Care plans for people were detailed around their needs with clear guidance for staff that ensured the appropriate care was provided.

People had access to meaningful and person centred activities. There were times where people in their room were left without much social interaction however the manager started to address this on the day of the inspection.

There was a complaints procedure and complaints were recorded appropriately with information around how there were responded to.

There were effective systems in place to assess and monitor the quality of the service. Audits and surveys had been undertaken

This was a follow up visit to check that the provider had achieved compliance with cleanliness and infection control following our previous inspection. During this inspection we looked at this one outcome. People we spoke with told us the home was always clean. One person said “The place is spotless.” A second person said “My bedroom is cleaned every day and my bed linen is changed regularly.” A third person said “Staff work so hard to keep the home clean.”

Staff had told us they guidance they had access to had improved and showed us a number of documents and guidance regarding infection control. Cleaning schedules were detailed and this enabled the reader to have a clear understanding of the tasks that needed to be carried out. A new system of audits had been implemented and were being embedded into practice.

People told us that they had been involved in discussions about their care and support needs and that they had enough information to enable them to make choices and decisions about the way they spent their time at the home. People told us they were happy at the home and stated that the staff were "Good" and, "Patient." Staff had a range of detailed information to guide them in the provision of care and support to people. Care records were personalised and had been improved to include detailed risk assessments and specific care for people who had complex needs.

People were supported to eat and drink suitably nutritious food and commented, in the main positively about food and the support of staff. Food was said to be "Very nice" and "Generally good." Staff were observed to carry out their supportive duties with compassion, respect and afforded people due dignity.

The environment was suitably clean; however there were deficiencies in the systems and processes for monitoring standards of cleanliness and therefore people were potentially exposed to risk of infections. Measures had been taken to upgrade the sluice area, removing the former risks to staff and improving this environment for them.

There were effective recruitment procedures in place so that people could be confident the right people were employed in the service.

During our inspection we spoke with seven people living at Hydon Hill. All of their comments to us were favourable about the home, the manager and staff.

One person told us that the staff were fantastic and very kind. This person also told us that the care and the food was very good.

Another person told us that they took part in a lot of activities; they liked the new bathrooms and toilets and felt that things in the home, especially the cleaning, had been improving.

We saw that people enjoyed healthy banter with staff and one person was talking with the volunteer in the homes shop. We saw that the service provided transport for eight people to go out for the day to have a Christmas lunch.

We saw that visitors were welcomed by staff and all the people we spoke with told us that staff worked really hard and were very loyal to the manager and their colleagues.

We found that some of the records kept by the service were not up to date and the sluice room was in a poor state of repair.

People told us that they liked the new dining area and that they felt better having their meals in a ‘real’ dining room.

People commented that the toilets were being re-furbished and they had been included in choosing the colour schemes.

People told us that they liked living at Hydon Hill.

We were told that the managers and staff were helpful and kind and helped people to be independent.

Were told that there was always things to do and that people felt included in the running of the service and could have their say.

Some people using the service could not tell us directly about their care due to a variety of complex needs so we relied on other people living at the service and visitors to tell us about their views and experiences.

People we spoke to said they were given time to express their views and were involved in making decisions about the care and support they needed and staff members support them to be as independent as possible and their views and experiences are taken into account.

One person staying at Hydon Hill for respite care said they enjoyed their stay and felt that their needs were well met by staff.

People who use the service said that they generally felt safe and knew how to raise a concern or make a complaint if they needed to.

People’s relatives told us that they were generally informed about matters that affected their family members and were kept informed and involved in their relative’s care. This had not always been the case as communication was not always consistent yet this had improved due to the appointment and experience of the care co-ordinator.

People using the service said that they thought the activities were well organised and enjoyed participating in them.

Some people’s relative’s, however, told us that they did not always feel confident that the care staff and the registered nurses communicated well enough with each other regarding people’s care needs. Some people’s relatives felt that there seemed to be a lack of nursing care at the service in which to promptly address and respond to any changes in people’s condition and care.

People’s views about the food at the service was varied. Some people said they were eating too much because the food is so nice and they eat a lot of salads and others said they did not like food but said they had choices if they didn't like what they had ordered.

Some people said that there was lots of variety and that they had meetings about the food and what they said about the food was listened to by the chefs and staff.

One visitor at the service said they thought the food was very good and had improved recently with the appointment of another chef who had some good ideas.

People who use the service and some visitors said they thought that improvements could be made as their rooms were not always cleaned and left as tidy as they would like.

One person said that they liked their bed and felt it was very comfortable.

We spoke with one person using the service who said that they didn’t like sitting in their wheelchair as the seat was uncomfortable and nothing had been done about it to make it more comfortable for them.

Some people said they liked their rooms being at the front of the building as they were able to see what was happening outside and liked to go out into the gardens.

Some people’s relatives commented upon the poor state of the toilets and the outdated and poor decorative order in the service.

There were mixed views about the staff as some people said that they thought staff members were diligent and dedicated in their duties yet some staff did not always show an interest in their work and lacked commitment.

Hydon Hill Nursing Home provides nursing and personal care for up to 46 people. There were 36 people living at the home at the time of the inspection. They had a range of complex health care needs which included people who have multiple sclerosis, acquired brain injuries stroke, and injuries sustained as result of an accident. Most people required help and support from two members of staff in relation to their mobility and personal care needs.

Hydon Hill Nursing Home is owned by and run by Leonard Cheshire Disability which is a charity that states it provides care and support to people with physical disabilities helping them to fulfil their potential and live the lives they choose.

Hydon Hill is a purpose built single storey accommodation set in extensive grounds and surrounding woodland. The accommodation had been adapted to meet people’s individual and complex needs. It was accessible to wheelchairs throughout. There was a large activity room and a physiotherapy room which people were able to use throughout the day. Due to its remote location, accommodation in chalets set in the grounds was available for staff and volunteers if they wished.

There is a registered manager at the home. 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.

This was an unannounced inspection which meant the provider and staff did not know we were coming. It took place on 9 and 10 November 2015.

People’s safety was compromised in a number of areas. Care plans did not all reflect people’s assessed level of care needs and care delivery was not person specific or holistic. We found that people with specific health problems such as diabetes or those who required catheter care did not have sufficient guidance in place for staff to deliver safe care. Not everyone had risk assessments that guided staff to promote people’s comfort, nutrition, and the prevention of pressure damage. There was no guidance to ensure equipment used to prevent pressure damage was set correctly. This had resulted in potential risks to people’s safety and well-being.

People and staff did not feel valued by the organisation. They did not feel they were involved or informed about the day to day running of the home.

There were not enough staff on duty to meet people’s needs in a person-centred way. This meant care was task orientated and reflected the number of staff on duty rather than people’s individual needs.

Quality assurance systems were in place. Areas for improvement had been identified and an action plan was in place to address these, however, the provider had not ensured action was taken when needed to meet regulatory requirements.

Staff knew people well, they were kind and treated people with compassion and patience. However there were occasions where people were not treated with dignity and respect. People were not always attended to in a timely way and their personal preferences, lifestyle and care choices were not always met.

Arrangements for the training, supervision and appraisal of staff were in place. However, staff had not received clinical training updates or ongoing professional development through regular supervisions.

People were supported to have enough to eat and drink however their nutritional assessments and care plans did not contain sufficient information to provide guidance to staff. Food was freshly cooked each day and people were provided with choices. The cook and staff had a good understanding of people’s dietary needs.

Mental capacity assessments were not in place and did not meet with the principles of the Mental Capacity Act 2005, as they are required to do so. There was information to show people’s consent had been sought in relation to some decisions however there was no information to show people had capacity to consent.

People spoke well about the support they received from staff. Staff interactions demonstrated they had built good relationships with people and staff were passionate about ensuring people lived a life which helped them achieve their potential.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action.

We found a number of 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 this report.