The inspection took place on 28 and 29 September 2015 and was unannounced. Hill House is registered to provide accommodation with nursing care for to up to 60 older people who may experience dementia. Nursing care is provided to people across three floors. People who experience dementia are accommodated on one of two ‘Safe’ units which are located on the ground and first floors. At the time of the inspection there were 54 people living at the service.
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.
Staff had not always fully completed people’s fluid charts as required, although they had identified when people were not sufficiently hydrated and referred them to the GP for further assessment. There were discrepancies between stocks of some medicines and the number there should have been if medicines had have been administered as prescribed. This created a potential risk people may not have received these medicines. We have made a recommendation that the provider refers to best practice guidance in relation to standards of record keeping.
People and their relatives told us the service was safe. Staff had undergone relevant training and understood their role in relation to safeguarding people. The provider had reported safeguarding incidents to the local authority and CQC as required.
Staff had completed a range of risk assessments in order to identify and manage risks to people in relation to areas such as mobility, falls and skin integrity. When people experienced a fall they had been monitored, the GP was informed and their care plans updated where required. Risks were discussed with people and their relatives so they could make informed decisions about how to manage them. Staff understood the risks to people and followed guidance to ensure their safety.
There were sufficient staff deployed to meet people’s care needs and arrangements were in place to meet any shortfalls. Staff were deployed according to people’s needs and the skill set of individual staff. Staff had undergone the required recruitment checks. The recruitment process had been effective at identifying unsuitable staff.
Medicines were safely ordered, stored and administered. Where people’s medicines were administered covertly legal requirements had been met. Staff had guidance in place for the administration of people’s ‘as required’ medicines. Nurses received regular updates on their medicines training. People received their medicines safely.
Staff underwent an induction to their role and received on-going training. Care staff were supported in their daily work by more senior staff and expected to undertake professional qualifications. Nurses received a range of training opportunities to enable them to evidence their on-going fitness to practice. In addition to the provider’s in-house training staff undertook training in collaboration with external agencies on topics such as hydration and falls. Staff received regular supervision and received an annual appraisal of their work. People were supported by staff who underwent a range of training to ensure people’s care was based on best practice.
Where people lacked the mental capacity to make specific decisions, staff were guided by the principles of the Mental Capacity Act 2005. This ensured any decisions made were in the person’s best interests. The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. DoLs applications had been submitted for people where required. People’s liberty was only restricted when this was legally authorised.
People were offered a range and choice of nourishing foods during the day. Risks to people from malnutrition had been identified and managed effectively. If people were at risk their foods were fortified to ensure they received sufficient calories. Staff understood people’s dietary requirements and preferences.
People were supported by staff to access a range of health care professionals as required in response to their identified health care needs. Staff had good working relationships with external health care professionals and ensured their guidance was incorporated into people’s care plans.
The provider had given consideration to people’s needs in the design of the building and in particular to the needs of people who experienced dementia to ensure the environment was suitable for them, for example, in the positioning of pictures to orientate people.
People and their relatives told us staff were caring. Nursing and care staff were encouraged to build relationships with people and their relatives. Staff encouraged the families of people who experienced dementia to complete life history books to enable them to understand more about the person’s life and their personal interests. Staff understood people’s care needs and preferences. They supported people to express their views and to make choices. Staff had undergone relevant training to ensure they understood how to uphold people’s privacy and dignity. People and their relatives told us staff applied this training in the provision of people’s care. Staff were observed to provide people’s care in private.
People’s care needs had been assessed on their admission to the service. They had a named nurse who was responsible for their care planning. They ensured the involvement of the person or their family in their care plans and regular reviews of people’s care were completed. People had care plans which detailed how their identified needs would be met. There were processes in place to ensure staff had up to date information about changes in people’s care needs and to ensure people were checked upon regularly. People were encouraged to participate in a range of activities across the week to ensure their social care needs were met.
The provider had a process in place to enable people to make both verbal and written complaints. Records demonstrated people’s complaints had been investigated, actions taken and feedback provided.
The provider audited a range of aspects of the service on a monthly basis. The results of the audits were then reviewed by the senior management team in order to identify any trends and to identify areas for improvement. The provider used a national safety tool to monitor the risk of people experiencing harm. They had also developed clinical pathways for staff to follow with an external professional to promote effective care for people based on evidence based practice. The views of people and their relatives were sought through meetings and feedback forms. People’s feedback about the quality of the service had been acted upon.
People, their relatives, staff and professionals all provided positive feedback about the quality of the management of the service. Management was visible at all levels of the service, the registered manager was readily available to people. The registered manager wished to step down from their role. During the handover period to the new manager, the provider had identified issues with the new manager and as a result they were in the process of replacing them. This had placed additional pressure on the registered manager which may have contributed to the issue we identified with the quality of some records.
There were processes in place to enable staff to have the opportunity to meet with the provider and to raise any issues as required. People’s care delivery was underpinned by a clear set of values which staff learnt about during their induction.