This inspection took place on 21 February, 12 March and 3 April 2018. The first day of our inspection was unannounced and the two following days were arranged in advance. Hilltop Manor Care Home Limited is a ‘care home’ in the village of Sherburn-in-Elmet. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.
The service is registered to provide residential care for up to 35 older people, some of whom may be living with dementia, a physical disability, detained under the Mental Health Act or with mental health needs. At the time of our inspection 34 older people were living at the service.
There was a registered manager in post who was also one of the owners of the service. A registered manager is a person who has registered with the 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.
At our last inspection in January 2016 we rated the service ‘Good’ overall. At this inspection the provider required improvement in the safe, effective, responsive and well-led domains. They were therefore rated Requires Improvement overall. This is the first time the service has been rated Requires Improvement.
Staffing levels at night were not safe. The provider did not have a robust system to assess, monitor and ensure staffing levels were safe.
At our last inspection we recommended the provider review the processes to support staff, with a particular focus on supervisions. These concerns had not been addressed and we found staff did not receive the required number of supervisions in line with the provider’s policy.
Staff completed training in areas the provider considered mandatory. However specific training, in areas such as dementia care and nutritional support, had not been consistently completed. We found three separate instances where staff required further medication training, due to medicine administration errors, and this had not been completed. The provider did not have a clear policy about how often the care worker’s competency to administer medicines should be assessed.
The provider had a programme of quality assurance checks to monitor the safety and quality of the service provided. The checks were limited in their scope and did not highlight the issues we found during our inspection. This increased the potential risk to people and resulted in a breach of governance.
We found breaches of regulation relating to staffing and the governance of the service. You can see the action we asked the registered provider to take at the back of the full version of this report.
The provider took some actions to address our concerns which included an increase of staff on duty at night, the development of a dependency tool to assess the minimum number of staff required and considered ways to improve their system of governance.
Risk assessments were completed when areas of risk had been identified. However, risk assessments and care plans were not updated when there had been a change in a person’s needs or following an accident or incident. Daily records highlighted issues but did not describe the follow-up actions taken by staff. Reviews of people’s support were completed but did not evidence they were included in discussions about their care.
Accidents and incidents were recorded, but we found these lacked detail about the management and response to the incident and any lessons learnt.
A fire risk assessment was completed in 2012 but there was record of this been reviewed to ensure it was still up to date. There were also no records of night staff having completed fire drills. Following the first day of our inspection a fire drill was completed.
Medicines were stored and administered appropriately. Protocols to describe when ‘as and when needed' medicines should be administered were not always in place and handwritten entries on people’s medication administration records were not consistently countersigned. We recommended the provider implements best practice guidance in relation to medication administration.
Staff continued to be recruited in a safe manner. Care was provided by a consistent staff team. Staff understood signs of abuse and knew how to report their concerns. This ensured people were protected from abuse.
At the last inspection we recommended the provider consider best practice in relation to a 'dementia friendly' environment and noted parts of the service required redecoration. At this inspection we found heavily patterned carpets had not been replaced, there was limited signage to enable people to move around the building unaided and the décor required updating.
People who used the service and their relatives told us they enjoyed the food. People were regularly weighed and staff sought the support and advice of professionals when there were concerns about weight loss.
People were supported to have maximum choice and control of their lives and staff supported people in the least restrictive way possible; the policies and systems in the service supported this practice.
People told us staff were kind and respected their privacy. Staff had a good knowledge of people’s likes, dislikes and needs. Staff had established a rapport with people’s relatives. People were provided with dignified end of life care.
Various activities were available, which included crafts, playing quizzes and watching performances. Activities coordinators were employed at the service and had worked with healthcare professionals to develop stimulating and person-centred activities for people.
People who used the service and their relatives told us they felt able to report any concerns to the staff or management team. The overview of complaints required further development to ensure this demonstrated a clear and transparent approach to investigating complaints.
Resident and relative meetings were held to hear people’s views on the service and ways in which it could improve.
The management team received positive feedback from staff, the people who used the service and their relatives.