Hilltop Hall Nursing Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We found four continued breaches of regulation. This included continued concerns in how people received safe care including how people’s needs and risk were safely managed and lessons were effectively learnt following incidents and the management of medicines; continued concerns in relation to how the provider ensured there were suitably numbers of experienced and competent staff including agency staff who were suitably inducted to the service and had the knowledge they needed to support people and continued concerns with how the provider safely recruited staff and ensures all staff, including agency staff on duty were suitable for these roles. The service did not always have safe systems for appropriate handling of medicines. Whilst improvements had been made, the recording of creams and ‘when required’ medicines was not safe. The provider did not have effective oversight of incidents to ensure lessons were learnt effectively and embedded and all required action was taken to mitigate risk as much as possible. Staff were not always suitably supported in their role through supervision and appraisal and had not always been safely recruited. There were ongoing concerns in regard to the management of oversight and induction for agency staff. However, people felt staffing levels had improved.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were not aware of how incidents and accidents were used to learn lessons and did not appear to be involved in any processes around this. Records showed that some lessons were being learnt by the provider and staff. For example, we observed people going out on trips and their time sensitive medicine being taken with them to ensure this was not missed. However, this was not consistently the experience for all people where there had been an incident. Lessons learned were not being completed for all incidents which may have identified areas for improvement for people living at the service.

Staff and the management team told us that since our last inspection more lessons learnt had been completed when things went wrong to help drive improvement. However, we noted there were times when management made decisions not to complete analysis or lessons learnt, for example in relation to a tablet which had been found on the floor in somebody’s bedroom.

The provider had failed to action and embed effective processes to ensure lessons were learnt to ensure people were kept safe from avoidable harm. There was limited evidence that processes for capturing incidents and accidents were being effectively used. For example, incidents around medicines and opportunities for learning were not captured in these processes. There was no robust formal system for oversight and analysis and documentation was not always of sufficient quality. Lessons learned were not being completed for all accidents and incidents at the service. For example, where people had multiple falls, there was no evidence at the time of assessment, of analysis around this and efforts to reduce the risk of further falls. Following the assessment, the provider has submitted documentation of analysis of a person’s fall, however it does not reflect all the guidance given to them and the ongoing circumstances with the person.  At the previous inspections, multiple areas of requiring improvement had been identified. There were longstanding shortfalls in how the provider identified and managed risks to the safety of people and a number of these areas of improvement had still not been addressed at this visit. There were no formal processes in place for the provider to share learning across all their homes to drive improvement at provider level.

People generally appeared to feel they were suitably supported and received the care they needed. However, we were not assured that guidance from professionals was always being followed. One person had additional guidance in place following a fall at the service and this information was not included in any care planning or referred to in care notes which placed them at increased risk of harm.

Staff told us they were informed of people’s needs when they move into the service. Since the last inspection, there had been limited new admissions to the service to demonstrate these processes were being used effectively.

Partner agencies generally felt people were currently supported to access other healthcare services. Safeguarding investigations indicated that there had been delays in referrals to other professionals and further work was needed to ensure these risks were mitigated.

The provider had not embedded processes to ensure safe systems and pathways were in place and followed. Care plans did not consistently show that robust pre-admission assessments had taken place to ensure people’s needs were appropriately assessed and planned for. Multiple assessments were incomplete or had not been started. One person who was reluctant to have their wound dressing changed did have appropriate evidence of referrals and escalation. However, their care plans did not evidence that all possible options to encourage regular redressing of wounds had been considered. These concerns were also highlighted at the last inspection. It is unclear what action the service had taken to address this.

People told us they felt safe at the service. One person explained that staff supported them with their personal care, promoted good hygiene and made them aware of the consequences of poor hygiene and the potential impact on their health and wellbeing. People were supported safely with moving and handling and where issues were identified, for example, staff moving a person in a wheelchair without footplates, this was quickly identified and addressed. However, other examples indicated positive risk taking such as around diet was not always supported or understood.

The management team had good oversight of the current safeguarding investigations and understood the importance of responding to the local authority’s requests for information and evidence. Staff were aware of the signs of abuse and how to report any concerns. Staff demonstrated good knowledge of escalation procedures and how to act if concerns were not being appropriately raised by the management team.

We observed people were cared for appropriately with their basic care needs. We observed mix examples of how staff supported people with positive risk taking.

The service had a safeguarding policy in place which was in line with local guidelines. Safeguarding information was available around the home. Staff had received training in safeguarding. The service had a log in place to monitor the status of ongoing safeguarding investigations. However, we found some shortfalls in how the service understood risk taking for people assessed to have capacity and capacity assessments were not always very clear or detailed to provide the guidance staff needed to support people to stay safe.

People and families told us were not always involved in decisions around how risk was managed, and information was not always accurate to ensure people received the care they needed, and risk was well managed. One person told us they were able to go out to smoke or go out into the community as they wished.

The management team were not able to give us assurance about how people were involved in managing risk and making decisions.

We observed staff made attempts to include people in day-to-day decision making.

Care plans lacked detail on how people were involved to manage risk and how risk was to be mitigated, for example in relation to falls prevention. Some care plans specific to a person’s needs, such as in regard to their emotional wellbeing and distress had not been implemented. Where people had capacity but needed additional support to communicate their choices, there was no record to show how they were involved in these choices. The management team had collated information around where people had legally authorised representatives to make decisions on their behalf, but it was not evident that this was used to ensure people’s involvement in decision making. The provider continued to have insufficient oversight in relation to the management of risk.

People did not always have an environment which met their needs. We found that some people’s bedrooms that were personalised and homely but some areas of the home were cold, or windows were open. People were given blankets for warmth rather than windows being closed.

The management team acknowledged further work was needed to drive improvements in the environment. At the last inspection, a fire risk assessment had identified multiple fire doors required improving or replacing. The management team explained that due to the volume of work required this had been prioritised in order of risk and was not able to be completed within the recommended timelines. At this assessment, significant progress had been made, and the work was almost completed.

We observed some areas of the home were cold but some areas of the home had been redecorated. There were limited adaptations in place to meet the needs of the various service user groups the service supported which included people living with dementia, and people with physical or sensory needs.

The provider had not taken the action required to ensure staff were always being recruited safely. For example, we found one staff member did not have appropriate pre-employment and right to work checks had not been completed robustly. This person’s file had been reviewed twice as part of an internal audit and these issues had not been addressed. The service used agency staff on a regular basis to support their staffing levels. The provider did not demonstrate how they were assured that agency staff were suitably skilled to support people. Accurate records regarding agency staff were not consistently held. There were some agency staff working on site who had no records of completing an induction at the service. This was a repeated concern on the last three inspections. Staffing levels appeared appropriate. However, it was not clear how the tools reflected the staffing rotas as rotas were not accurately maintained with the names of agency staff working. The management team explained that the agency staff who attend the service often changed, and the rotas were not updated to reflect this. The full names of staff were also not included on the rotas which made it difficult to accurately identify which staff had worked at the service from the rota. There continued to be shortfalls in the management of agency staff profiles and inductions were not in place for all staff who had worked at the service. It was therefore not clear how the service had assured themselves that staff were suitable and safe to provide support to people at the service. We continued to find shortfalls in terms of how staff were supported with supervision and appraisal.

People gave mixed feedback about the staffing levels. Some people described having to sometimes wait for support for slightly longer periods of time. One person told us “I use a call bell sometimes. I do have to wait a bit but not too long. They might be busy elsewhere.”

Staff spoke positively about the staffing levels at the service and having the time to support people to take part in things they enjoyed. The staffing levels had not been reduced, despite a significant reduction in occupancy which gave staff more time to support people. Staff expressed some concerns about what might happen when the service occupancy began to increase again, as they had previous experienced difficulties due to not having enough staff on duty.

Staff were available throughout the service to support people in a timely way. During lunchtime, there was some confusion around communication between kitchen staff and care staff to ensure people had meals they wanted and that were appropriate for them.

The provider had not taken the action required to ensure staff were always being recruited safely. For example, we found one staff member did not have appropriate pre-employment and right to work checks that had been completed robustly. This person’s file had been reviewed twice as part of an internal audit and these issues had not been addressed. The service used agency staff on a regular basis to support their staffing levels. The provider did not demonstrate how they were assured that agency staff were suitably skilled to support people. Accurate records regarding agency staff were not consistently held. There were some agency staff working on site who had no records of completing an induction at the service. This was a repeated concern on the last three inspections. Staffing levels appeared appropriate. However, it was not clear how the tools reflected the staffing rotas as rotas were not accurately maintained with the names of agency staff working. The management team explained that the agency staff who attend the service often changed, and the rotas were not updated to reflect this. The full names of staff were also not included on the rotas which made it difficult to accurately identify which staff had worked at the service from the rota. There continued to be shortfalls in the management of agency staff profiles and inductions were not in place for all staff who had worked at the service. It was therefore not clear how the service had assured themselves that staff were suitable and safe to provide support to people at the service. We continued to find shortfalls in terms of how staff were supported with supervision and appraisal.

People gave positive feedback about the cleanliness of the service. Bedrooms were evidently clean. One person said, “I can’t fault the cleaner, they do a great job.”

Staff felt supported to provide good cleaning provision at the service. At the time of the assessment, the service had recruited two additional domestic assistants to support with the cleaning schedule.

We observed the service appeared clean throughout and there were no malodours. Domestic staff took pride in their work. There were good supplies of personal protective equipment (PPE) available throughout the service.

Cleaning schedules were well maintained and updated. There was a programme of daily, weekly and monthly cleaning tasks to be completed.

People did not raise concerns. one person told us “I have no complaints about how they sort my medicines out.” People who had thickening powder added to drinks because of swallowing difficulties were administered this safely and records were completed accurately. Information to support people to take their medicines safely when they needed to be crushed was clearly documented. We saw that medicines rounds were organised and completed in a timely manner so that people got their medicines when they needed them. For people with diabetes, blood tests were carried out regularly. These tests along with insulin administration were recorded correctly. Person-centred information was not always in place to support staff to safely give ‘when required' medicines to people. This included medicines that might control behaviour. There was a risk that people might not have got their medicines when they needed them.

Managers told us that staff had completed medicines training and had been recently assessed to ensure that they gave medicines safely. We were shown evidence of training records to confirm this. Managers provided evidence that regular medicines audits were being carried out. However, these did not always identify issues that were picked up during this assessment. Whilst medicines incidents were recorded and analysed, there was not an effective process in place to ensure that lessons were always learnt.

There was an effective process for managing stocks levels. Records of controlled drugs were accurate and made in line with legislation and best practice. Medicated patches were applied and recorded correctly, with enough information available to do this safely. For example, site of application and patch rotation. However, a robust process for applying creams to people was not in place. Staff did not always record when and where a cream had been applied. There was a risk that they were not being applied as prescribed. Overall, medicines were stored safely and securely. However, creams were kept in people’s rooms without appropriate storage risk assessments being completed. There was a risk that they could be inappropriately accessed.