Hillcroft House

Updated 18 October 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by an inspector.

Service and service type

Hillcroft House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. [Care home name] is a care home [with/without] nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection a registered manager had not been in post since July 2022. The current interim management arrangements of the home included the provider’s regional manager and a registered manager from one of the provider’s other homes. The provider had recently appointed a new manager due to start in the home the following week and they would initially be supported by the current interim management arrangements.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 28 September 2022 when we visited the home and ended on 7 October 2022 when detailed feedback was given.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with five people who lived at Hillcroft House to seek their reviews of their care and support. Not everyone who used the service were unable to tell us about their experience of receiving the service, so observations of care and support were also made. We spoke with two people’s relatives and a healthcare professional when we visited the home.

We also spoke with representatives from the provider this included a regional director, regional manager, operation’s manager, a health and safety manager and a registered manager from another of the provider’s homes. We spoke with the deputy manager, two seniors, six care staff, maintenance person and three ancillary staff. We also written feedback from four relatives and three staff.

We reviewed the care records of four people who used the service and several medicines records. We also reviewed a range of records in relation to the governance and management of the service, including audits, policies and procedures, training information and the recruitment records of three staff members.

Updated 18 October 2022

Hillcroft House is a residential care home providing accommodation and personal care for up to 43 people. At the time of our inspection there were 36 people living in the home, most of whom were living with varying levels of dementia.

People’s experience of using this service and what we found

We found concerns at our last inspection and rated the home requires improvement in two key questions and overall. We also found a breach of the Health and Social Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found that the provider was no longer in breach and had made the necessary improvements.

People told us they felt safe and we observed they were at ease in the company of the staff that cared for them. People were protected from the risk of potential harm; safeguarding policies and processes were in place and staff had received appropriate training.

Risks to people were regularly assessed with measures in place to mitigate them. This included timely referrals to healthcare services. Safe management of medicines was in place.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

There were sufficient safely recruited staff on shift to meet people’s needs. The provider was actively recruiting additional staff but in the meantime was using preferred agency staff, where required, to maintain safe staffing levels. We have made a recommendation about staffing.

Despite recent changes in the leadership in the home, staff were clear on their roles and responsibilities. Morale and the culture in the home was good, staff said the interim management arrangements the provider had taken had settled the home and staff felt supported in their role.

Governance systems supported the provider and management team to identify shortfalls in the home and address them. Processes were in place to learn lessons when things had gone wrong with actions taken to reduce future incidents happening.

Overall, the home was clean and hygienic with good infection control procedures carried out. Staff wore appropriate personal protective equipment (PPE). We noted that some parts of the home were in need of attention and this was addressed during our inspection. The management team shared the provider’s programme of scheduled works which included improving the décor and layout of the home to benefit the people living there.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 28 April 2020) and there was a breach of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of the regulation.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from Requires Improvement to Good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Hillcroft House on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.