Hilltop Court Nursing Home

Hilltop Court Nursing Home is a residential care home providing personal and nursing care to up to 50 people. The service provides support to older people, some of whom live with dementia. At the time of our inspection there were 42 people using the service.

Hilltop Court Nursing Home accommodates people across two separate floors, each of which has separate adapted facilities.

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

There had been changes of the entire management team since our last inspection. This meant some areas of improvement hadn’t been fully achieved due to a lack of consistency. Existing systems in place failed to always identify the ongoing shortfalls we found throughout this inspection.

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 provider had not ensured this in the absence of a manager, although policies and systems were in place to support best practice. The provider had introduced new systems to monitor quality, however these were yet to be embedded to enable sustained improvements to be demonstrated.

Although we found some improvements were still needed, we did observe positive and caring interactions between staff and people living at Hilltop Court Nursing Home. Staff sought consent before providing care and demonstrated an understanding of people’s preferences.

The communication needs of people were clearly documented, and people had access to appropriate healthcare services.

Checks were in place to ensure people lived in a safe environment. Ongoing refurbishment and redecoration of the home was planned.

Appropriate checks on staff were in place to ensure they were suitable for the role before working with people. Staffing levels were safely planned, and were determined by people's needs.

People were protected from the risk of abuse. Systems were in place to monitor and appropriately report accidents and incidents to external agencies.

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 14 April 2022). 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 the provider remained in breach of regulation, however the provider had met the warning notices we had issued.

At our last inspection we recommended that the provider considered current guidance on the safe and appropriate use of tilt-in-space recliner chairs. At this inspection we found the provider had acted on this recommendation and had made improvements.

The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections.

Why we inspected

We carried out an unannounced inspection of this service on 1 February 2022. Breaches of legal requirements were found. We issued two Warning Notices in relation to Regulations 9 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and the provider completed an action plan to show what they would do and by when to improve safe care and treatment.

We undertook this inspection to check whether the Warning Notices we previously served had been met. We also needed 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, Effective, Responsive and Well-led which contain those requirements.

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.

For the key question not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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

Enforcement and Recommendations

We have identified an ongoing breach in relation to effective governance and provider oversight at this inspection. Please see the action we have told the provider to take at the end of this report.

We have also made recommendations in relation to consulting with people around meal options and developing a varied plan of activities for people to enjoy whilst living at Hilltop Court Nursing Home.

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 meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. 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.

Hilltop Court Nursing Home is a care home providing personal and nursing care to up to 47 people. The service provides support to older people. At the time of our inspection there were 37 people using the service. The care home accommodates people in one adapted building across two single-sex units.

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

Medicines were not always managed safely which placed people at risk of harm. People had risk assessments and risk management plans in place to provide safe care and support. We have made a recommendation about the safe and appropriate use of reclining chairs. The home was clean and had infection control measures in place. Staff knew how to safeguard people from harm. Staff were recruited safely. Health and safety checks of the environment had been completed.

Some staff were attentive and caring; however, we observed some staff did not always interact with people or speak kindly. Parts of the home felt clinical and not homely, and people’s rooms were not always personalised. Improvements had been made in the provision of oral healthcare and bedroom privacy since the last inspection.

We made a recommendation at the last inspection regarding activities. However, we found there were very little activities and social stimulation at the home. There were no person-centred, individualised activities for people. Care plans contained lots of information to direct staff on people’s every day care needs. However, we found a lack of detailed information about people’s individual preferences to ensure staff knew how they liked to have their care provided.

Systems and processes to ensure oversight of the service were not always effective. Audits completed had not always identified the concerns we found on inspection. We identified multiple and repeated breaches of regulations. The management team were helpful and quick to investigate when we fed back our findings during the inspection.

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 29 September 2021) and there were breaches of regulations. 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 the provider remained in breach of regulations.

At our last inspection we recommended that the provider referred to current best practice to prioritise meaningful interaction for people cared for in bed. At this inspection we found improvements still needed to be made regarding interactions between staff and the people they cared for.

The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

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. This included checking the provider was meeting COVID-19 vaccination requirements.

We received concerns in relation to medicines, accurate documentation, management, health and safety, staffing levels infection control, moving and handling and personal care. As a result, we undertook a focused inspection to review the key questions of safe, responsive and well-led only.

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 remained requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, responsive and well-led sections of this full report.

The provider was transparent and responsive throughout the inspection and took action to attempt to mitigate the risks we identified.

You can read the report from our last inspection, by selecting the ‘all reports’ link for Hilltop Court Nursing Home on our website at www.cqc.org.uk.

Enforcement

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 management and administration of medicines; person-centred care and management oversight at this inspection.

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

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 report being published to discuss how they will make changes to ensure they improve their rating to at least good. 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.

Hilltop Court Nursing Home is a nursing home providing personal and nursing care to older people living with dementia. The service can accommodate up to 50 people and at the time of our inspection there were 36 people living at the home. Hilltop Court Nursing Home accommodates people in one adapted building over 3 floors in two single-sex units.

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

Activities were taking place in parts of the building, but people cared for in bed were at risk of social isolation. We made a recommendation about activities.

Care plans were not always person-centred and care was not always delivered in line with people’s assessed need. People did not always have window covering to provide privacy.

Policies and systems were in place to help make sure medicines were managed safely. People felt safe and were protected against the risk of abuse. The provider had robust infection prevention and control procedures to protect people from cross infection. Staff were recruited safely and there were enough of them to meet people’s needs.

People were supported to have maximum choice and control of their lives and staff always supported them in the least restrictive way possible and in their best interests; the policies and systems in the service promoted the least restrictive practice. However, two people who could carry their own bedroom door keys told us they had to ask staff to unlock doors so they could access their own bedroom.

We found shortfalls in the provider’s systems to assess, monitor and improve the service. The accuracy and quality of records was inconsistent. This could have compromised the safety and quality of the service. The management team were receptive and keen to make improvements. Following our inspection, they acted immediately to address the shortfalls in standards we identified.

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 25 March 2020). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about person-centred care. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

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

Enforcement

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to hydration and nutrition, oral healthcare, privacy and record keeping 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 report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

About the service

Hilltop Court is a nursing home providing personal and nursing care to older people living with dementia. The service can accommodate up to 50 people and at the time of our inspection there were 41 people living at the home. Hilltop court accommodates people in one adapted building over 3 floors in two single-sex units.

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

We identified concerns with the accuracy of care documentation, and we found concerns regarding the notification and management of safeguarding incidents. At the time of the inspection significant improvements had been made since the intervention of the local authority. However, our pharmacy inspector found continued concerns with the management of medicines. Staff recruitment files were not always complete.

Sufficient staff training, supervision and oversight of staff competency was not in place. Staff had not always received training in mandatory subjects. Consent had been given by relatives where no legal safeguards were in place for them to make those decisions. People’s nutritional and hydration needs were met and staff were knowledgeable around these needs

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 always support this practice.

We received good feedback about how caring staff were when providing care and support. We observed some particularly caring staff. However, we also observed some instances where people were not treated with dignity and were not talked about respectfully.

People’s care plans were comprehensive and written in a person-centred way and included information on people’s specific communication needs. Activities were well resourced and included personalised activities alongside group activities.

There has been a lack of oversight of the operations of the service and this has led to the concerns identified in this inspection. Statutory notifications were not sent to CQC as required. The provider had already started to make improvements and was working closely with the local authority to ensure the safety of people at 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.

The last rating for this service was Good (2 August 2019).

Why we inspected

The inspection was prompted in part due to concerns received about unsafe medicines management. A decision was made to inspect and examine those risks.

Enforcement

We have identified breaches in relation to people’s dignity and respect, consent to provide care, providing good governance of the service and the training and supervision of staff at this inspection.

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

Since the last inspection we recognised that the provider had failed to notify us of certain events. This was a breach of regulation. Full information about CQC’s regulatory response to this is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

About the service

Hilltop Court Nursing home provides personal and nursing care to people living with advanced dementia.

People’s experience of using this service

Relatives were very positive about the service and the care provided. One told us, “It’s been every bit as good as when we first came. By and large I think it’s one of the best homes.”

People were cared for by staff who knew how to keep them safe and protect them from avoidable harm. There were systems in place to ensure only staff who were suitable to work with vulnerable people were recruited. There were sufficient staff to provide the appropriate level of support to people.

Staff received the training, support and supervision they needed to carry out their roles effectively.

People received their medicines as prescribed and there were systems in place for the safe storage, administration and management of medicines.

Risk assessments had been completed. These helped identify if people were at risk from everyday harms, such as falls or choking. Where risks had been identified, there were plans in place to guide staff so that people were kept safe.

The building was well-maintained and decorated. Equipment was of a good standard and was serviced appropriately. The premises were clean and staff followed infection control and prevention

procedures.

The requirements of the Mental Capacity Act 2005 were being met. People were helped to make choices, if they were able. Staff supported them in the least restrictive way possible.

People were supported to eat a well-balanced diet and were offered a choice and variety of meals.

Relatives were complimentary about the staff and management team. Staff interacted with people in a kind, caring and patient way, and respected their privacy and dignity.

A wide range of activities were provided and social interaction was encouraged. Where people were unable to take part in group activities, staff spent time with people on an individual basis.

Staff were extremely responsive to people's individual needs and wishes and had an in-depth knowledge about each person. Care records were comprehensive.

The service provided exceptional end of life care.

The registered manager provided good leadership of the service and was committed to maintaining and improving standards. Staff and relatives told us they felt supported by the registered manger. Audits and quality checks were undertaken on a regular basis and any issues or concerns addressed with appropriate actions.

Rating at last inspection

Requires Improvement (report published August 2018). Following the last inspection we asked the provider to complete an action plan to show how they would improve the service. At this inspection we found the service had made the required improvements.

Why we inspected

This was a scheduled inspection based on the previous rating.

Follow up

We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

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

We also checked that improvements to meet legal requirements planned by the provider after our comprehensive inspection which was undertaken on 27 and 28 November 2017 had been carried out. These related to breaches of Regulation 12 of the Health and Social Care Act 2008 (Regulation Activities) Safe Care and Treatment and Regulation 17 of the Health and Social Care Act 2008 (Regulation Activities) Good Governance. The home was rated requires improvement in safe and well led with an overall rating of requires improvement. At this inspection although improvements had been made to the shortfalls we found at the last inspection, further shortfalls were found.

The registered provider sent us an action plan. This action plan was not yet out of the set timescale given by the registered provider. However, contact was made with the registered provider who agreed that we could check what improvements had been made since our last inspection. We also looked at additional continuous improvements made by the registered manager since our last inspection.

Because of the concerns we had received an adult social care services inspector and a specialist professional advisor (SPA) who was a qualified Speech and Language Therapist (SALT) undertook this inspection. A SALT is a qualified healthcare professional who provides treatment, advice, support and care for people who have difficulties with communication and/or eating, drinking and swallowing. At this inspection we only focussed on the safe and well led sections of the report. The last comprehensive inspection can be found on our website www.cqc.org.uk/sites/default/files/new_reports/INS2-3069399060.pdf.

Hilltop Court Nursing Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Hilltop Court Nursing Home accommodates up to 50 people on two floors in single sex units. The home provides care to people living with advanced dementia. A person who is living with the later stages of dementia is likely to experience severe memory loss, have problems communicating with others and need additional support with daily activities, including eating and drinking.

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. There was a registered manager in place at the time of our inspection.

We found that the health and safety shortfalls we found at the last inspection had been satisfactorily addressed. Stairwells were kept free from electrical items, and the outstanding item on the homes fire risk assessment had been completed and signed off. A risk assessment had been carried out for mouse bait visible in the dining area and maintenance books had been to be signed off by a senior person.

We looked at the arrangements for monitoring nutrition and hydration for people including the risk of choking. We were told that when the home made a referral to the speech and language team there could be a delay of up to four weeks before the person had a speech and language therapist (SALT) assessment undertaken, which meant the home was reliant on developing their own risk assessments. However, there was no clear evidence on the service's records to indicate there could be a delay of up to four weeks before an assessment could take place.

Risk assessments used to determine people’s level of choking risk were not always effective in capturing all the potential signs of aspiration and/or choking. One record we saw showed that it had not been kept under regular review.

We found discrepancies in the records we saw between a care plan, daily recording and handover sheet in terms of texture of food requirements. The handover sheet used between different teams of staff identified those people at high risk of choking and we found this was out of date and contained the names of several deceased people.

We found evidence of a ‘near miss’ which had occurred that had not been formally reported. The lack of reporting was a missed the opportunity to report to senior management an incident that may indicate the need for higher levels of supervision in order to minimise risk to that individual.

The registered manager demonstrated a good understanding of some of the signs of aspiration and potential choking and expressed confidence in her staffs’ knowledge and responsiveness to such signs. However, staff training records did not indicate that staff had received the training they needed to increase their awareness of the risk of choking and to help prevent it from happening. The registered provider took immediate action to ensure that this training would be undertaken by all staff and completed by 30 June 2018.

You can see what action we told the provider to take at the back of the full version of the report.

The registered provider had started to take action to help reduce the risks identified by the Coroner. This included introducing two sittings for meals. One for those people who eat in the dining room and a second sitting to enable staff to support people who eat in their rooms and for those people who choose to walk and eat to ensure any discarded food is disposed of safely. The registered manager and care quality lead informed us that since the incident there had been and increase in staffing levels to support people safely and effectively.

We observed a pleasant and positive mealtime experience for those people using the service. There was a good balance between supporting people and encouraging them to be as independent as possible. Appropriate texture of food and drink was provided at lunch.

Basic information on diet modifications for each person was kept on a laminated sheet in the dining room. Daily recording on an online system contained regular references to food and fluid intake people had taken and written records were also appropriately maintained.

Staff members in the dining room were responsive to individual people’s needs and personalities and were quick to pick up if someone needed help. They worked well as a team to achieve this.

A new “patient passport” document was in the process of being implemented and eleven had been completed by the end of the inspection. These patient passports will include more detailed information on patients’ eating and drinking needs, as well as communication needs and other health support requirements.

We were informed that a SALT student placement programme was due to start at the home in the near future. If supported correctly this may help to increase awareness of the eating, drinking and communication needs of people within the service.

We saw that the registered manager had been proactive in looking at ways to improve the service. The Stockport Red Bag Pathway is an initiative to improve communication between the hospital and the home. The registered manager was in the process of arranging to take student nurses for practice placements and arranged training sessions with a local healthcare provider about catheterisation and blood taking in exchange for the staff from the local healthcare provider to attend dementia, mental capacity act and deprivation of liberty safeguards (DoLS) training. During the forthcoming dementia week the registered manager of the home had made arrangements to provide dementia awareness sessions at two high schools in the local area.

Hilltop Court Nursing Home is a ‘care home’. 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, the care provided, and both were looked at during this inspection.

Hilltop Court Nursing Home is situated close to Stockport town centre. The home provides nursing and personal care for up to 50 people. At the time of our inspection, 46 people were living at the home. People who used the service lived with advanced dementia. The home was on three floors named Coronation Avenue, Emmerdale Close and Wembley House.

We last carried out a comprehensive inspection on 31 August and 1 September 2016. At this inspection, we found the service was in breach of the regulations relating to the management of medicines and people's care and treatment records in relation to people's religious, cultural and end of life wishes and the availability of these records to all staff. The overall rating for the service was requires improvement.

We returned to the service to carry out a focussed follow up inspection on 25 April and 3 May 2017. Although we saw improvements had been made in relation to people’s care records, there were still shortfalls in the management of medicines. The service was rerated to good. It should be noted that changes in our methodology on 1st November 2017 a service can no longer be rated good if it is in breach of a regulation.

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 is the service safe and well led to at least good. At this inspection, we found that improvements had been made in relation to medicines management. However, we found concerns around the health and safety of the premises in relation to window restrictors and fire safety.

The service had a registered manager in place. 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. The registered manager was present during most of this inspection.

We raised concerns about fire safety at the premises and requested a visit by the Greater Manchester Fire and Rescue Service. We also raised concerns about the lack of tamper proof window restrictors in parts of the home. Action was taken to address this matter during the inspection.

Although the registered provider’s quality assurance systems were identifying health and safety concerns, timely action to resolve them was not always taken.

You can see what action we have asked the registered provider to take at the end of the main report.

We recommend that all recent recruitment files are reviewed to ensure that the service is meeting requirements to ensure references are taken up with previous adult and children services employers.

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Staffing levels were sufficient to meet the needs of people who lived at the home.

Staff had received training in safeguarding adults. They were able to tell us of the action they would take to protect people who used the service from the risk of abuse.

Improvements had been made in medicines management. Systems were in place to reduce the risk of cross infection in the service; this included the use of personal protective equipment (PPE) where necessary and regular checks regarding the cleanliness of the environment.

Risk assessments were in place on people’s care records to minimise the potential risk of harm to people during the delivery of their care.

The registered manager understood the requirements of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). This meant they were working within the law to support people who may lack capacity to make their own decisions.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible.

Staff had access to the training they needed to help support people safely and effectively. The registered provider had improved facilities for staff training and the registered manager was involved in developing more practical based and interactive dementia training with the online training provider.

People had limited verbal communication due to living with dementia. We observed staff providing support to people in a kind and patient way. The atmosphere at the home was calm and relaxed.

Care records we saw showed they were kept under reviewed however; more evidence was needed to show the involvement of family and friends.

The home provided a wide range of activities for people to be involved in, which included short bursts interactions to keep people stimulated. The home was working on a project with the Alzheimer’s Society to look at the best ways to engage with people who live with advanced dementia.

There was a complaints procedure, which was on display. A record of all complaints and the action taken to resolve them was maintained.

The registered manager was working towards strengthening the management team but needed to be sure potential new management staff had the right communication skills and personal qualities to work with people living with advanced dementia.

Care staff and relatives we spoke with gave positive responses about the care people received at Hilltop Court.

At our last inspection on 31 August and 1 September 2016, we found two breaches of the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulations 2014 relating to safe care and treatment and person centred care.

Following the inspection the provider sent us a plan of the actions they intended to make to meet the relevant regulations. This inspection was carried out to check that the provider had met the breaches in the regulations. This report only covers our findings in relation to this topic. You can read the report from out last comprehensive inspection by selecting the ‘all reports’ link for ‘Hilltop Court Nursing Home’ on our website at www.cqc.org.uk.

Hilltop Court Nursing Home provides accommodation for up to 50 people who live with advanced dementia. There were 47 people using the service at the time of our visit.

The service had a registered manager in place, though they were not available 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.

At our last inspection, we found two breaches in the regulations related to the management of medicines and the lack of religious and cultural preferences on people’s care and end of life plans. Following the inspection the provider sent us a plan of the actions they intended to take to meet the relevant regulations.

At this inspection, we found that although significant improvements had been made the service was in continuing breach of the regulations in relation to medicines management. The breaches related to, incomplete medicines administration records (MAR), the arrangements for administering medicines covertly in food, the lack of ‘when required’ PRN protocols and temperatures to the medicines fridge temperatures.

You can see at the back of this report what we have asked the provider to do.

At this inspection, we found that the records relating to people’s religious and cultural preference had improved. Care records had been put onto a new electronic system and were accessible to staff at all times via laptops iPads, although the iPads were not operational during our visit. We were informed that 25 advanced care plans had been completed and the outstanding advance care plans were on-going with arrangements being made with families or solicitors. We were also informed that a Greater Manchester Ambulance Service liaison officer was also coming in to talk to families and relevant others of people who use the service. We recommend that the service completed the remaining records as far as practicably possible to do so.

Hilltop Court Nursing Home provides accommodation for up to 50 people who were living with advanced dementia. There were 44 people living in the service on the day of our inspection. We were not able to speak to people who used the service to ask them questions due to the nature of their diagnosis and lack of capacity. We therefore spoke with relatives and staff members and undertook observations around the service.

The service had 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.

During this inspection we found 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.

Medicines were not always managed safely. This was because the administration of medicines was not always as prescribed, there was a lack of information available to staff on medicines that were to be taken ‘when required’ and one person was self-administering one of their medicines despite lacking capacity and with being risk assessed. We also checked controlled drugs within the service. A large surplus of one medicine could not be accounted for.

Staff members told us that although sometimes they felt as though there was not enough staff, they always managed to meet the needs of people who used the service.

We found risk assessments were in place in relation to the environment and possible hazards. Care records we looked at showed that individual risks to people had also been considered and protective factors identified to keep people safe.

Recruitment processes and systems in place within the service were robust. This meant that people who used the service were protected against the risk of unsuitable people working within the service.

We saw no evidence that nursing staff had received clinical supervision. The managing director could not tell us if these were being completed and the registered manager was not available to ask. We have made a recommendation that the service considers clinical supervisions for all the nursing staff.

Records we looked at showed that people had been assessed in relation to their capacity. These assessments had been undertaken by the relevant and appropriate people and had involved the person and their family. We also saw that best interest meetings had been undertaken for those people who lacked capacity to consent.

DoLS applications, which CQC should be made aware of, had been notified to us in a timely manner. We saw information to show that authorisations to deprive people of their liberty had been made to the relevant supervisory body.

We checked the kitchen and found adequate supplies of fresh, fresh, tinned and dried food was available. The service had a 5* rating from environmental health. All the relatives we spoke with told us the food was good. We have made a recommendation that the service considers current best practice guidance in relation to supporting people with advanced dementia during mealtimes.

Activities on offer within the service included, film night, board games, armchair exercises, ‘news and natter’, arts and crafts, entertainers, afternoon tea, karaoke and pyjama days. We observed one person was sat in the garden with their relative enjoying the good weather.

We looked at a number of policies and procedures during our inspection. We found these were robust and would support staff members in their roles.

Regular residents and relatives meetings were held in the service. One was being undertaken on the day of our inspection which we attended. We saw people and their relatives were given the opportunity to comment on the service.

People were given documentation called a Service User Guide when they were admitted to the home and a copy was available on the entrance notice board. This gave people a welcome to the home statement and informed them of the philosophy of care.

The registered manager told us they sent out questionnaires to relatives as a means of gaining feedback about the service.

During the previous inspection we also found that people were not protected from the risks of unsafe or inappropriate care and treatment because care records did not reflect their individual needs. We judged that this had a major impact on people using the service and enforcement action was taken against the provider.

Two inspectors visited the service on 28 October 2014 to carry out an unannounced inspection.

At the time of this inspection we were told that 44 people were accommodated in the home.

During this inspection we spoke with the manager, four members of staff, the director of care and looked at records.

We considered the evidence collected at this inspection and addressed the following questions, is the service effective and is the service well-led?

Below is a summary of what we found. Please read the full report for the evidence supporting our summary.

Is the service effective?

Since our last visit to the service we found there had been improvements in the training staff were receiving. Evidence was available to demonstrate that staff had received training in various subjects such as Dementia Care, Mental Capacity and Deprivation of Liberty Safeguards. The numbers of staff attending and completing each training course varied and the manager told us that all training was ongoing until all staff had completed all training relevant to their job role.

Is the service well-led?

At the previous inspection we had concerns that people were not protected from the risks of unsafe or inappropriate care and treatment because care records did not reflect their needs. Due to those concerns enforcement action was taken. During this inspection visit we found that the records relating to peoples individual needs had significantly improved but did still need some further development.

Staff were now receiving supervision on a more regular basis and the manager confirmed that she was planning for all staff to receive supervision at least bi-monthly and we will check this again at our next visit to the service.

Is the service safe?

All the people who were living at Hilltop Court Nursing Home were living with dementia and could not always give their verbal opinions on the service they received. However, we observed during our visit that people were treated kindly and with respect. We were also able to understand from the people we spoke with that they were happy living at the home.

We saw and overheard one person to be displaying some challenging behaviour towards two staff at the home. From our observations and from talking to the two staff involved it was clear that they lacked the necessary skills and training to help them to effectively de-escalate the behaviour.

Each person had an individual care file that included some risk assessments and a care plan that described how to meet individual care needs. The care plans we looked at were found to lack detail of how staff should effectively meet peoples care needs and some identified care needs did not have a plan of care in place. These shortfalls meant that people could be at risk of not having all of their needs appropriately met.

Visiting relatives told us that they were pleased with the care their relative received.

During our visit we looked at the premises to see if they were suitable for their intended purpose. We found the premises to be suitable and there was evidence of ongoing maintenance at the home.

During the inspection we saw some areas that required extra cleaning. For example we saw the base of the hoist was dirty, there was an unidentified brown substance on the side of a small coffee table in the ground floor lounge and there was what looked like encrusted food on a pressure cushion on one of the chairs in the ground floor lounge. These issues were discussed with the director of care during this inspection and on the second day of inspection we were informed that the identified areas had been cleaned.

Is the service effective?

During this inspection we saw the quality of food provided was of an acceptable standard. We saw that choice was given with regard to the main part of the meal, however everybody was given the mash potato, vegetables and gravy without being asked if they wanted it. We saw that gravy and mash potato was served with Italian meatballs with pasta in a tomato sauce which seemed a strange combination. This was discussed with the management team during this inspection.

We looked at the staff training records and noted that staff had been provided with mandatory training but not other training relevant to their job role for example Dementia Care, Dignity in care and managing behaviour that challenges. Staff had not received adequate supervision or appraisals. This meant that people were at risk of not having their health and welfare needs met by trained, competent staff.

Is the service caring?

The atmosphere in the home felt busy and chaotic. Although staff were busy they were seen to be responsive to people's needs. From our observations we saw that care staff had a good understanding of people's individual needs and personalities.

We observed that people were freely moving around the home.

The people we spoke with who were living at the home indicated that they were happy living at the home.

Is the service responsive?

We saw that where appropriate the service had accessed advice and care from other health care professionals. For example we saw evidence of visits to the GP, the chiropodist, the opticians and we saw that people attended hospital appointments. This meant the provider sought relevant professional advice and guidance appropriately.

Is the service well-led?

At the time of this inspection the newly appointed manager had only taken up post three days previously.

At the inspection in January 2014 we had concerns because records did not reflect the individual needs of people who used the service and placed people at risk of inappropriate care and treatment. Shortfalls were again found at this inspection and therefore enforcement action is being taken.

In response to the information received a compliance manager and a compliance inspector inspected the service during the early hours of the morning.

During our visit we spoke with the nurse in charge and the four care staff on duty.

During this inspection we spoke with two people who lived at the home who said they were happy with the care and support provided and how they were looked after. They told us that staff respected their rights, privacy and dignity. Comments included; "staff are super" and "I'm happy here."

We also spoke with the home manager, the quality assurance manager and people who worked at the home. We spoke with four family members who regularly visited the home. We were told they considered the care to be good. We looked at three care records and saw that these required further information to enable staff to deliver safe and effective care.

We saw that since the last inspection, the company which owned the home had appointed a quality assurance manager to introduce a series of audits at the home. We saw that audits had been completed. However we noted that falls audits had been completed in advance and did not reflect the information within the care files. We also saw that care records audits had been completed and these did not reflect the information within the files we viewed.

At our last inspection we saw that staff had not received sufficient training, supervision and appraisals. At this inspection we saw that some training and supervisions had been completed and that appraisals were being planned.

During our visit we spoke with a director of the service, the registered manager, the deputy manager and members of staff.

We spoke with four family members whose relatives used the service. They all told us that the home consulted with them on a regular basis and they considered the care to be good.

We used a number of different methods to help us understand the experiences of people using the service. This was because some of the people using the service had complex needs. We also spoke with three people who lived in the home and all told us that they liked living at the home.

We looked at a selection of care records. We had concerns regarding a person's plan of care.

We found although the service had some quality assurance systems in place, some were being developed.

The home had effective systems in place to ensure people were cared for in a clean and hygienic environment.

We viewed the training and supervision provided to staff and this was an area of concern.

We found the lack of consistent recording systems meant that there is a risk that information may not be kept up to date and people are not protected against the risks of unsafe or inappropriate care and treatment.