Archived: Greenhill House - Care Home with Nursing Physical Disabilities

About the service

Greenhill House - Care Home with Nursing Physical Disabilities is a residential care home providing personal and nursing care for up to 38 people whose primary need is physical disability. People had a range of other complex needs including mental health, learning disabilities, autism, acquired brain injuries and degenerative health conditions. At the time of the inspection, 34 people were living at the home across two main buildings and a coach house with four flats. Each person had an individual bedroom with shared bathrooms, lounges, dining areas and kitchenettes.

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

People were not experiencing care that was safe or well led. Systems were not in place to effectively manage the home as there had been a period of unstable management. There were insufficient systems to ensure people were supported by enough skilled staff. There was a negative culture within the home and staff were not always recognising poor practice. Audits were incomplete, contained inconsistencies or did not exist.

People spent long periods of time with minimal interaction from staff. Neither did people have care that was personalised to their needs and wishes. Care plans contained contradictions and multiple versions of the same document. People had not always seen health professionals in a timely way. Improvements were found with systems to monitor people’s human rights and around medicine management. Representatives of the provider had worked hard at the home to try and stabilise areas such as safeguarding practices even with changes in management at the home. This meant they were being reactive rather than proactive.

Right Support:

People were not living in a home that currently promoted choice, control and independence. Staff lacked time and skills to support many people to go out of the home or participate in meaningful activities in the home. Some people were sitting with minimal interaction from staff for long periods of time. Others with more mobility could choose to move themselves around the home.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Right Care:

People’s dignity was not always respected due to a negative culture amongst staff as a result of mixed leadership. Some staff tried their best to have positive interactions with people. However, many would walk through communal areas not acknowledging people. Staff were not challenging poor practice which did not protect people’s dignity.

Right Culture:

People were not living inclusive and empowered lives at the home due to an unstable management. There had been three home managers since October 2022 and multiple deputies to support them. Representatives of the provider based at the home had been reactive rather than proactive due to the level of concerns and issues. Systems were only emerging or not in place to manage the home.

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 7 December 2022).

The provider completed an action plan after the last inspection to show what they would do and by when to improve. However, we inspected due to further concerns received including from the provider.

At this inspection we found the provider remained in breach of the regulations. Although small improvements had been made in medicine management.

Why we inspected

We undertook a focused inspection to follow up on specific concerns which we had received about medicines management, staffing and safe care and treatment. The provider had raised concerns related to an unstable management prior to this inspection. A decision was made for us to inspect and examine the risks to people. When we inspected, we found there were wider concerns including around person centred care, dignity, staff training and delays to see some health professionals. So, we widened the scope of the inspection to cover all five domains.

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.

Enforcement

We have identified breaches in relation to dignity and culture, person centred care, safe care and treatment, staffing, staff training, governance and infection control at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this inspection. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

About the service

Greenhill House – Care Home with Nursing Physical Disabilities is a residential care home providing personal and nursing care for up to 38 people with physical disabilities as their primary need. People also had complex needs including a learning disability, autism, mental health, acquired brain injury and life limiting health conditions. At the time of the inspection there were 38 people living at the home.

The home has three buildings. Four people lived in flats for more independence. Everyone else was in one of the two main buildings on the site. Communal spaces were available in both such as lounges and dining rooms. There were also shared bathrooms.

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

People were not supported by enough staff who had the right skills or were deployed effectively to meet their needs and wishes. Medicines were not always being managed safely and people were not protected from cross-contamination. The home had not been well managed, and many shortfalls were found. The provider and new management had identified most of these already and action was being planned to rectify them.

Right Support:

People were not being supported by enough staff to maximise their choice, control and independence. Access to the community for people to receive support in line with their wishes was not in place. Support around medicines and infection control was not always safe.

Right Care:

Care plans were sometimes incomplete or had not been updated so lacked details for staff to follow to ensure consistent care was delivered. They also had not identified or mitigated all risks to people. A high level of agency staff led to people receiving inconsistent care not always in line with their needs and wishes.

Right Culture:

Staff lacked the culture, values, behaviours and attitudes to ensure people had care in line with current best practice guidance, legislation and standards. They would not correct each other or ensure the provider’s values and systems were being followed.

The new management displayed a high level of transparency and placed the people at the heart of everything. Detailed action plans were in place to rectify the shortfalls so people could live confident, inclusive and empowered lives. However, it was too early to say if this would be successful.

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

Rating at last inspection

The last rating for this service was good (published 13 March 2021).

Why we inspected

We received concerns in relation to staffing, risks to people and management of the home. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Greenhill House – Care Home with Nursing Physical Disabilities on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safe care and treatment including management of risks, infection control and medicine management. We also found issues with staffing and staff culture at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

People were comfortable in the presence of staff wearing masks and visors whilst supporting them. They nodded and gave us thumbs up when we asked if staff always wore masks. Staff and the management were proud they had worked hard to keep COVID-19 out of the service.

Staff were aware of how to use personal protective equipment (PPE) such as masks, aprons and gloves. This included for procedures which required more specialist masks. Throughout the inspection we saw appropriate use of PPE. Staff knew how to safely wash their hands to reduce the risk of infections spreading. There were numerous hand sanitiser stations throughout the home in key places such as entrances and exits.

The management ensured staff worked in ways to reduce the risk of infections spreading by having specific staff teams working in different parts of the service. However, this had not extended to auxiliary staff because they had a shortage. During the inspection the registered manager informed us this had been rectified and they would be allocating auxiliary staff to parts of the service as well.

Staff and people were being tested regularly to identify cases of COVID-19. They had just received the lateral flow tests although these were not implemented at the time of the inspection. The registered manager told us they had been discussing with their line manager how these could safely be introduced. However, the provider had taken a stance of not implementing them following their research into the efficacy of them.

People had visitors if they were nearing end of life. However, because there was currently a national lockdown the provider felt it was unsafe to have visitors to the home to keep people safe. There had been times during the pandemic that visiting had occurred including in the grounds and a celebration over Christmas. Systems were in place to make sure these visits were safe and in line with guidance.

Regular cleaning had happened throughout the home. This was predominantly by auxiliary staff. Care staff informed us that they were responsible for further informal cleaning by wiping down surfaces and cleaning computers. However, the management had not considered increasing the frequency of cleaning of high touch points in light of the new strains of COVID-19. During and following the inspection we were informed this had been reviewed.

Management systems to monitor actions taken during the COVID-19 pandemic were predominantly informal. Staff confirmed they had been observed putting on and taking off PPE by senior staff. The staff also confirmed they helped by undertaking additional cleaning alongside twice daily cleaning undertaken by auxiliary staff. However, there were no formal systems for the management to demonstrate they were monitoring that this happened. Following the inspection, the registered manager shared updates as to how they would rectify this.

The inspection took place on 9 August 2018 and was unannounced. At our last inspection in May 2017 we found that the service had not ensured that all peoples' consent and best interest decisions were recorded in line with the Mental Capacity Act 2005 Code of Practice.

We also found at our last inspection that the lack of Mental Capacity training for staff had not been picked up swiftly by the provider’s quality monitoring systems. There were still areas that required improvement such as a review of best interest decisions and consent recording in care plans.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions the service Effective? and is it well Led? to at least good.

We found that people's rights were now protected because there were effective systems in place to ensure that the requirements of the Mental Capacity Act 2005 were followed. This law protects people who lack capacity to make informed decisions in their daily lives. The provider had completed applications when needed under the Mental Capacity Act 2005 Deprivation of Liberty Safeguards. This helped ensure that the necessary safeguards were in place for the people concerned.

There was a registered manager for the service. 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 were positive in their views of the staff and the support given by staff with their range of needs.

People were treated in a kind and caring way by staff who staff spent plenty of time with people and engaged with them very positively. We saw that there were warm and good-humoured interactions between them.

People were supported to take part in a variety of social and therapeutic activities. Technology was used in an innovative way to promote independence and support people in their daily lives.

The provider’s quality monitoring systems were now effective. Areas of the service that required improvement such as a care plans, training and staff support and supervision were identified. Actions were taken to address any shortfalls in the service.

During the August 2016 inspection, eight breaches of the Health and Social Care (Regulated Activities) Regulations 2014 were found in relation to person centred care, need for consent, safe care and treatment, premises and equipment, staffing and good governance safeguarding service users from abuse and improper treatment, receiving and acting on complaints and requirement as to display of performance assessments. There was also a breach of Regulation 18 (Registration) Regulations 2009: in relation to notification of other incidents. We found there had been insufficient improvements to the service since being placed into special measures. The service remained in special measures and was rated inadequate for a second time. As a result conditions were placed on the provider’s registration to encourage improvement to the service.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements at its next comprehensive inspection and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We carried out a comprehensive inspection of Greenhill House on 24 and 25 May 2017. This inspection was unannounced. Regulatory breaches from the August 2016 inspection were followed up as part of our inspection. At this inspection the provider had made sufficient improvements to be removed from special measures.

You can read the report for previous inspections, by selecting the 'All reports' link for ' Greenhill House - Care Home with Nursing Physical Disabilities Nursing Home' on our website at www.cqc.org.uk

Greenhill House is a nursing home with a total of 37 beds. The service is split between two individual units; one providing residential care and the other providing nursing care to people living with physical disabilities. At the time of our inspection there were 37 people living in the service.

There was 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.

The provider had improved the quality monitoring systems which were used to bring about improvements to the service. Some improvements had yet to be embedded by the service.

The service had failed to ensure that best interest decisions were recorded effectively when people lacked the mental capacity to make decisions and give their consent. We have made a recommendation to the service about this.

Training in the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS) had been provided to staff. DoLS aim to protect people living in care homes and hospitals 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. Staff were knowledgeable about the protection of people’s rights.

Medicines were managed and stored safely. Medicine administration records were complete. We observed that medicines were administered to people as prescribed.

People’s needs were regularly assessed and resulting care plans provided practical guidance to staff on how people were to be supported. Care plans were person centred and contained individual information and references to people’s daily lives. People’s risk assessments reflected necessary actions to reduce risks to people.

There were positive and caring relationships between staff and people at the service. People praised the staff that provided their care. We received positive feedback from people’s relatives and visitors to the service. Staff respected people’s privacy and we saw staff working with people in a kind and compassionate way when responding to their needs. People were supported to undertake person centred activities.

There were enough staff to meet people’s care needs. Staff demonstrated a detailed knowledge of people’s care and support needs. Staff had received training to support people safely and respond to their care needs. Staff were aware of the service’s safeguarding and whistle-blowing policy and procedures.

There was a robust staff recruitment process in operation. The recruitment process was designed to identify staff that had the ability to develop their skills to keep people safe and support their needs.

People had access to healthcare professionals when required, and records demonstrated the service had made referrals when there were concerns.

There was a complaints procedure for people, families and friends to use and compliments could also be recorded. The provider had made appropriate notifications to the Commission; notifications tell us about significant events that happen in the service. We use this information to monitor the service and to check how events have been handled.

Further information is in the detailed findings below.

At this inspection we found nine breaches of regulations. Five of the previous six breaches from the last inspection in December 2015 had been repeated. We also found three new breaches in relation to safeguarding service users from abuse and improper treatment, receiving and acting on complaints and requirement as to display of performance assessments. There was also a breach of Regulation 18 (Registration) Regulations 2009: in relation to notification of other incidents.

Greenhill House is a nursing home with a total of 37 beds. The home is split between two individual units; one providing residential care and the other providing nursing care to people living with physical disabilities. At the time of our inspection there were 37 people living in the service.

At the last comprehensive inspection this service was placed into special measures by CQC. At this inspection the overall rating for the service is ‘Inadequate’ and there is a continued rating of ‘Inadequate’ in the key questions of ‘Safe’ and ‘Well led’. This inspection found that there was not enough improvement to take the service out of special measures. CQC is now considering the appropriate regulatory response to resolve the problems we found.

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.

Overall we found that quality and safety monitoring systems were not fully effective in identifying and directing the service to act upon risks to people who used the service and ensuring the quality of service provision. Many of the regulatory breaches identified at the last inspection in December 2015 been not been remedied.

The registered manager had failed to make appropriate statutory notifications; notifications tell us about significant events that happen in the service. We use this information to monitor the service and to check how events have been handled. The provider had not displayed the latest inspection rating for the service on its website.

The registered manager had failed to report and take prompt action as required regarding safeguarding and adverse incidents appropriately.

Not all the premises and equipment were not properly maintained.

Staff had not received regular supervision; the provider had not ensured that staff performance and progress was monitored effectively and that staff had an opportunity to voice their individual views. Staff told us that training did not meet people’s needs and we found that refresher training was frequently out of date.

Staff we spoke with had a good understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). The registered manager had made appropriate applications for DoLS where they had been required. 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.

Care plans and people’s risk assessments were incomplete and not reviewed as expected by the provider. Records used to monitor people’s health were not always completed.

The administration of people’s medicines was not in line with best practice.

The provider had a complaints procedure and people told us they could approach staff if they had concerns. We found however the registered manager was not recording informal complaints as described by the provider policy.

We had feedback from staff, people, visitors and relatives that the current staffing arrangements did not meet the needs of people using the service.

We received positive feedback about the care staff and their approach with people using the service; however we observed occasions when people’s dignity had been compromised.

Appropriate recruitment procedures were undertaken.

People had access to healthcare professionals when required, and records demonstrated the service had made referrals when there were concerns.

We found nine breaches of regulations at this inspection and will be asking the provider to send us a report of the improvements they will make.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Greenhill House is a nursing home with a total of 37 beds. The home is split between two individual units’; one providing residential care and the other providing nursing care to people living with physical disabilities. The home also offers day care for up to five people each week day.

The overall rating for this service is ‘inadequate’ and therefore the service is in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

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.

The quality and safety monitoring systems were not fully effective in identifying and directing the service to act upon risks to people who used the service. The compliance actions issued at the last inspection in December 2013 had not been met.

The home was not suitably clean. The hygiene practices of staff did not meet the Department of Health guidance for the prevention and detection of infection.

There were not sufficient numbers of staff to support people safely. We had feedback from staff, people and relatives that the current staffing arrangements did not meet the needs of people using the service. This was supported by our observations.

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

Risk assessments did not always reflect actions required to reduce risks to people. We saw that appropriate action was not taken in response to unsafe incidents, including steps to reduce the risk of them reoccurring.

The administration of medicines was not in line with best practice.

The provider did not have an effective system to monitor records made by staff or records that related to the management of the service. Records used to monitor people’s health and record best interests’ decision making were not always completed.

Training in the Mental Capacity Act 2005 had been provided and staff were knowledgeable about the protection of people’s rights. Despite this the provider had failed to ensure that best interest decisions were reviewed as expected.

We received positive feedback about the care staff and their approach with people using the service; however we observed occasions when people’s dignity had been compromised.

Staff appraisals and supervisions were not undertaken as planned. The registered manager failed to monitor and feedback on staff performance.

Staff felt that their views and concerns would be listened to but were not confident these would be acted upon.

Deprivation of Liberty Safeguards applications had been made for those people that required them. 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 provider had made appropriate notifications to the Commission; notifications tell us about significant events that happen in the service. We use this information to monitor the service and to check how events have been handled.

People had access to healthcare professionals when required, and records demonstrated the service had made referrals when there were concerns.

Appropriate recruitment procedures were undertaken.

The provider had a complaints procedure, and people told us they could approach staff if they had concerns.

We found six breaches of regulations at this inspection.

The premises were designed with people with a disability. Equipment was provided to meet the needs of people with complex disability needs. We saw much of the home needed attention; this meant the home had an institutional appearance. The new manager had an action plan in place to modernise and redecorate the home, to make it more homely. The action plan had been commenced but many areas still needed to be addressed.

People made positive comments about the staff. One person described them as 'fabulous.' Staff told us there had been improvements in staffing levels. One member of staff said staffing had 'definitely improved' and another 'there seem to be enough now,' about staff.

People's records were not maintained in a consistent way. Staff knew about people's care and treatment needs but matters they told us about were not documented. Records relating to prevention of pressure ulceration and skin care did not show how staff were preventing risk of tissue damage for people. Risk assessments were not consistently completed in accordance with national guidelines.

We found the provider had made some changes to the way work was organised in the morning. There was an additional member of staff to assist with breakfasts at the weekend. We saw some staff on the morning shift started 30 minutes earlier and there was an additional member of staff between 7am and 7.30am to assist people with their care needs.

Staff we spoke with thought the changes the provider had made enabled people to get up and receive support with their personal care routines at their preferred time.

We observed staff were patient and caring. There were some risks to people because there were not sufficient numbers of staff to meet people's needs. We found people often had to wait until late in the morning to be helped to get out of bed, washed and dressed to start their day. This meant some people had breakfast near lunchtime or missed morning activities.