Hill House

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• 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 identified 5 breaches of the legal regulations. Staff did not consistently protect people from abuse and improper treatment. Staff did not report when there were concerns with people’s support, that should have been investigated and reported as safeguarding concerns. Staff practice put people at risk of abuse when they were supported with aspects of support such as moving and handling or eating and drinking. Staff did not always assess risks to people's health and safety or mitigate them where identified. We found significant concerns in relation to poor medication administration practices at the service. Risk assessments in place for people were not always detailed or up to date and staff did not follow people’s risk assessments. The environment was not safe and was not being kept clean and free from IPC concerns, putting people at risk of harm. Staff were not having their training checked to help ensure they were competent to support people safely. Staff were not having meetings or supervisions to discuss their job roles and make improvements. Staff deployment at the service was not safe leading to people being unsupported for long periods of time. Staff recruitment checks were not being fully completed to help ensure staff were suitable to work in their job roles. However, people told us they felt safe living at the service. People were supported to safely transition to other settings such as hospitals if they needed this support.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us staff would change their practice if something went wrong. One person said, ‘‘I have had a couple of falls here, and I know [staff] wrote it in their books and put things in place.’’ However, relatives told us they were not always consulted when things happened to ask for their thoughts on improvements that could be made. One relative said, ‘‘Sometimes I do not get a call from the service even if [family member] goes to hospital. It would be nice to talk about what happened at the time.’’ Despite people’s feedback, people were not being support by a service with a strong learning culture as discussed in the other evidence categories in this quality statement.

Staff were not being supported to learn lessons when things went wrong. They were not being supported to discuss their performance in supervisions, nor were there frequent staff meetings where incidents and accidents were discussed, to see where things could be improved. Staff were not able to tell us how they were kept up to date with incidents that did happen, nor what they would do to help prevent future incidents from happening. The registered manager and management team did not have a full oversight of the service as audits did not fully cover accidents and incidents which had happened. For example, a person had a fall and was supported back to bed, rather than staff ringing for assistance from other services in line with the providers policy. This meant the person may have been supported unsafely, however the management team had not overseen this and taken action to help ensure this did not happen again. As a result, another incident of this nature happened.

Processes were not in place to promote a learning culture and help ensure improvements were made when things went wrong. The management team monitored incidents and accidents to identify where improvements could be made. However, these were not effective in monitoring for trends and the systems in place did not make it easy to identify when incidents or accidents should be investigated further. Staff did not report incidents or accidents effectively which led to an increased risk these would be missed and lessons could then not be learnt. The management team did not have processes in place to discuss lessons to be learned with staff. The management team had several improvement plans in place based on our previous inspection feedback and visits from partners such as the local authority. However, actions on these plans were not being actioned in a timely manner and some known areas of concern in relation to risk management had not been actioned for a significant period of time. For example, known risks in one person’s bedroom had not been addressed despite them being known about for 17 months when we started our assessment. This put people at risk of receiving unsafe care and support. The provider and management team had failed to implement improvements since our last inspection and were still in breach of the fundamental standards they were in breach of at our last inspection. This shows a lack of systems being in place to effectively support a learning culture at the service.

People and their relatives told us they were supported to go to health appointments such as to see their GP and were supported to go to hospital if this was needed. One person said, ‘‘The doctor comes every Thursday, and you can just request to see them. They had an optician in before Christmas and they have got a chiropodist as well. I suppose if you weren’t well [Staff] could get the Doctor in sooner.’’ A relative told us, ‘‘I think the reason staff know how to support [family member] well is because the hospital tell them how to do this whenever they go in.’’ The management team completed assessments of people’s needs when they started living at the service. However, people and relatives were not consulted about whether their support needs were still current on a regular basis. There was no evidence of people’s support needs being discussed with them or their relatives. One person said, ‘‘I can’t remember talking about what help I need. [Staff] just ask me if I am alright and if I want anything.’’ A relative said, ‘‘We are not contacted by the service to discuss [family member] or what is happening.’’ However, despite what people told us, information from health professionals and appointments were not always recorded in people’s care plans. Information was also not shared with staff members in meetings or supervisions to make sure they were aware of people’s new support needs. This meant there was a potential for staff to support people unsafely and not in line with advice from health professionals.

Staff were unable to tell us how they would know that people needed support from health professionals or may need a hospital appointment. Staff did not report concerns with people’s health and support in a timely fashion to the right professionals. For example, a person was not eating and drinking enough in line with their support needs and staff did not report this as a concern. Staff told us they did not have meetings to discuss changes to people’s support when they came back to the service from hospital and there was no recorded evidence of how this happened. This meant staff may not be up to date with people’s current support needs. The management team discussed the way in which people's needs were assessed when they started using the service. However, they were unable to show us how they ensured staff were kept up to date with people’s changing support needs following a visit to another service.

Professionals working with the service raised concerns about how competent staff were when supporting people to transition between services. One professional explained they did not feel staff were suitably competent to support people with moving and handling equipment when they needed to transition from one service to another. The professional told us, ‘‘It is concerning that staff do not seem competent to support people using [equipment] as this made the process of supporting the person to [service] slower than what it should have been.’’ Some professionals also fed back that they felt the service contacted them when people needed support. However, feedback from professionals was not being recorded in people’s care plans, nor was it being discussed with staff to help make sure they understood what the advice from health professionals was.

The management team assessed people’s needs when they first started living at the service. However, these assessments were not updated with people’s changing needs when they transitioned back to the service from different places. For example, one person’s care plan stated they were to be supported with a specific diet, which they were no longer to be supported with following a transition back to the service from hospital. This meant, there was incorrect information about the persons support in their care plans. This coupled with there being no processes in place to discuss people coming back to the service with the staff team, led to people being at risk of unsafe support. There were policies and processes in place for staff to follow when it came to identifying and supporting people to transition and use other services such as Speech and Language Therapist (SALT) or Physiotherapists. However staff did not always alert the management team when peoples needs changed and they needed further support. For example, when a person started having difficulties eating and drinking a timely transition to the SALT service was not made. When people accessed different health services and then came back to the service processes were not in place to make sure the support from the services they had used was recorded in the person’s care plans or daily records. For example, one person was to be supported to see a chiropodist on a regular basis however there were no records to show this was happening. This meant that people were not being supported to follow professionals advice and safely transition back to the service following using other services.

People and their relatives told us they/ their family member were safe living at the service. One person said, ‘‘I feel safe here. The building is very secure and ‘‘I feel perfectly safe here. I have got everything I need. The staff check on me to make sure I am alright. People can’t get into the building. I am not worried.” A relative said, ‘‘I have faith in the service that they keep [family member] as safe as can be.’’ However, some relatives told us they were not always assured their family member was safe. One relative told us they were concerned staff were not prompting their family members to drink enough. They said, ‘‘I was worried when [family member] went to hospital and were found to be dehydrated. [Staff] should know they need to remind them to drink, especially in the hot weather.’’ Another relative explained they were unsure why the management or staff team did not let them know when their family member had falls or what actions were taken to help these not happen again. Despite people telling us they were safe, the processes in place at the service did not keep them safe as explained in the rest of this quality statement.

Staff had training in safeguarding, however this was not being checked by the management team to make sure they understood the training. Staff were unable to tell us what signs may indicate people were at risk of abuse. Staff did not know who to report safeguarding concerns to outside of the service, such as to the local authority safeguarding team. The management team did not have a good oversight of people’s care plans and daily care records and were not aware of concerns that potentially should have been raised as a safeguarding concern. For example, if a person had a bruise or were not eating and drinking enough. The management team told us they were reliant on staff to tell them about potential safeguarding concerns and if they did not do this they would be unable to act. Staff were not competent to do this and the management team were not monitoring daily records, leading to potential safeguarding concerns being missed or not actioned appropriately.

People were not being safeguarded from abuse. During our site visits we observed multiple occasions where people were not supported safely. A staff member was supporting a person to eat and the person started to choke and cough. The staff member continued to put food in the persons mouth. We raised this concern with the local authority safeguarding team. One person was living with a health condition which meant they were more at risk of breathing difficulties. This persons room had not been upkept well and there were several areas of the room which were damp and posed a risk to a person living with breathing difficulties. This had been a known issue for a number of months, however no action had been taken to improve the environment of this persons room and safeguard them from abuse. We raised this concern with the local authority safeguarding team. We observed some people entering other people’s rooms when they were not invited to do so. Staff did not respond to this and were not present to support people not to go in to other people’s rooms. We had to alert staff to this several times during our site visits. One person explained, ‘‘I have had someone come into my room 4 times now. Last week someone came in and touched all my stuff on the window sill. I told the staff, but I don’t know if they have done anything to stop them coming here in the future. I know they are confused but I don’t really like it happening.” This meant people may be at potential risk of people going in to their rooms uninvited. People were not safeguarded from abuse in relation to how the building was being upkept and not being kept clean. We discuss this further in the safe environments and infection prevention control quality statements. People were not safeguarded from abuse by the poor medication processes at the service. We discuss this further in the medication quality statement.

There was a safeguarding policy in place at the service, however this was not being consistently followed by staff and managers. For example, staff did not know who to contact to report safeguarding concerns to and the management team were not reviewing people’s care records to help identify and report potential safeguarding concerns. There were no processes in place to review incidents and accidents with a view of identifying or discussing safeguarding concerns. We asked the management team to send us evidence of potential safeguarding concerns being discussed with the staff team to promote lessons being learned. The management team confirmed with us that these processes were not in place. This meant processes did not support people to be safeguarded from avoidable abuse or harm.

People and relatives told us they were supported to have risks to them assessed and plans put in place to support them with these. One person said, ‘‘I have had a few falls at the service and staff always record it in their books.’’ A relative said, ‘‘I know staff help [family member] to eat in line with their needs.’’ People and relatives told us they were not supported to be involved in discussing potential risks they may face. One person told us, ‘‘I cannot recall ever speaking about how things are going. Not sure if it is something staff should be doing or not.’’ A relative said, ‘‘I have never seen any care plans or risks assessments, nor have I been asked to talk about how best to support my [family member]. I would appreciate the opportunity though.’’ However, people were at risk of not being supported to have risks they may face mitigated as explained in the rest of this quality statement.

Staff were unable to tell us how to support people with their known risks. There was no evidence the risks people faced were discussed with staff in meetings or in supervisions. When risk assessments were updated there was no evidence to show staff members were kept up to date with these changes and staff members were unable to tell us how they were kept up to date with changes to people’s risk assessments. Staff told us they had not been supported to have time to sit and read people’s risk assessments in detail. Staff were not able to support people safely in line with their risk assessments as they were not competent in areas such as using moving and handling equipment or medicines administration. The management team told us they updated risk assessments on a monthly basis or when people’s needs changed. However, we found that this was not the case. They were unclear who was responsible for doing this and were not aware of some risk assessments being incorrect or not updated in line with people’s changing needs. The home manager explained they were under the impression other members of staff ensured these changes were updated however they were not checking to make sure this happened. This put people at risk of being supported unsafely.

We observed staff not supporting people in line with their risk assessments. For example, one person was a risk to other people as they tried to help them move unsafely. This persons risk assessment stated staff need to be available to support them not to do this. However, we observed multiple occasions during our site visit where this person was left unsupported with other people. This put people at risk of being helped to move unsafely. Another persons risk assessment explained to staff they needed support and prompting to eat and drink regularly to avoid malnutrition and dehydration. However, during our site visit we observed staff placing meals and drinks on this persons bedside table whilst they slept and did not prompt the person to eat or drink what was bought to them. Over the day multiple meals and drinks were stacked on this persons bedside table. This meant the person was not being supported in line with their risk assessments. People were not protected from risk in relation to how the building was being upkept and not being kept clean. We discuss this further in the safe environments and infection prevention control quality statements.

Processes were in place to update risk assessments on a monthly basis; however these were not effective. Risk assessments were not always updated when people’s needs changed. In some cases, multiple care plans for the same support need were stored in people’s documentation detailing different ways of supporting people. This meant staff may read the wrong care plan and support people unsafely Care plans and risk assessments did not give sufficient detail for staff to support people safely in areas such as moving and handling. They would state how many staff needed to support people, however not specifically how staff were to support people with these support needs. Processes were not effective in taking action to mitigate risks in relation to the environment at the service. We discuss this further in the safe environments and infection prevention control quality statements.

People told us they felt safe in their home environment. One person said, ‘‘It is nice and secure here and all the doors are locked so no one can come in uninvited.’’ However, people were not safe in the environment as discussed in the rest of this quality statement. One relative explained, ‘‘[Provider] continues to raise the fees we have to pay but does not seem to be making any changes or updating the environment.’’

Staff did not raise concerns with us about the environment at the service. However, a lot of areas of the building were unsafe and poorly kept, indicating staff did not see these issues as a risk to people. Staff told us maintenance staff dealt with any issues in relation to the environment, however the issues we found with the environment had not been addressed, despite being known about for some time. Staff explained they did not raise concerns about the areas that needed addressing as these had already been raised and would be actioned by maintenance staff. However, some known areas in need of decoration or fixing had not been addressed for periods of up to 15 months. During our site visits we walked around the service with the home manager who was upset by the areas of the environment we had concerns with. They explained they were not happy with the state of the environment and had raised this with the registered manager and staff multiple times but nothing had been done to rectify this. They told us they were aware the environment posed a risk to people, however were unable to tell us when the issues would be resolved.

The environment was not safe in a lot of areas of the service. Several store cupboards around the service which were used to store materials and cleaning products were open and not locked or secured. People living at the service had access to these materials and may have used them in an unsafe way. Several bedrooms at the service were in a poor state of repair. We observed wallpaper to be coming away from the walls, large cracks in walls and tiles and fragments of walls missing in en-suite bathrooms. These areas were visibly damp and mouldy leading to an increased risk to people living in these rooms. There were several pieces of furniture being used by people in their rooms which was damaged including a door to an en-suite bathroom, a chest of drawers and a chair. People were at risk from sharp protruding areas of this furniture. In one bedroom a fire door was hanging off of its hinge. This was a risk as the fire door would not have worked as intended had there been a fire at the building. Some materials were stored in cramped conditions in store cupboards increasing the risk of fire spreading should there be an emergency situation. We also observed the environment of the service to be dirty and not kept free from potential IPC issues. We discuss this in the infection prevention and control quality statement.

Processes were not in place to make sure the environment was safe to use or were ineffective in identifying where actions needed to be taken. We were not shown any audits which focused on the environment at the service. A service and decoration improvement plan had been in place at the service since 2020, however numerous actions to improve the environment noted on the plan had not been completed for an extended period of time. After our first site visit to the service we fed back about areas of the environment that were unsafe. When we returned to the service 8 days later no action had been taken to address the areas of the environment that needed to be made safe. Whilst there was a fire risk assessment in place at the service, this was not being used effectively to identify and mitigate risks in relation to fire safety. For example, a fire door with a broken hinge had not been fixed and crowded store cupboards had not been addressed. We raised our concerns with the local fire department during our assessment.

People told us they sometimes had to wait extended periods of time for staff support. One person said, ‘‘I have a call bell but it isn’t always left in my reach and I have to call out. [Staff] don’t have time to sit and chat to you.’’ Another person said, ‘‘Staff aren’t always around. I shout to go to the toilet. They said what are you shouting for. Several times I have had an accident which is not nice for me or for them.’’ Another person told us, ‘‘It might be once every week or it might be longer between showers. It depends how short staffed they are.’’ Some people also told is they felt there were enough staff. One person said, ‘‘There are always staff around and they do come to you quickly. I have got a call bell which I will use if I need to. They do sometimes sit and talk to you; it depends what is going on.” However, the deployment of staff at the service meant people were not receiving frequent staff support. Staff were not having their training checked to make sure they could safely and effectively support people and this put them at risk. We discuss this in the rest of this quality statement.

Staff told us they felt there were enough staff to support people safely. Staff told us they had training and completed most of this online. However, when we spoke with staff about their training, they were unable to tell us what they had learned or how they would apply this to their job roles. Staff told us they did not have regular supervisions or team meetings. Staff told us they did not have competency checks completed to help make sure their training had been effective. The management team explained they used a staff dependency tool to work out safe staffing levels, however, were not reviewing this or observing staff practice to help ensure staffing levels were correct. The home manager did not have oversight of staff training and told us this was the responsibility of another staff member who was not employed directly in a caring capacity. They confirmed staff were not receiving supervisions to discuss their practice and had not done so for 10 months. They also told us staff had not had competency checks completed in relation to key areas such as moving and handling. Staff were not being supported to have their received checked or be supported to discuss and develop in their job roles. This put people at risk of not being supported by competent and knowledgeable staff.

Whilst we observed there to be enough staff on shift to support people, staff deployment put people at risk. People were left for long periods of time, sometimes more than an hour in communal areas or their bedrooms without any staff support or interaction. This increased the risk of people not being able to ask for support or feel bored or socially isolated. One person was asking staff to use the toilet for over 7 minutes and staff continued to tell the person to wait until there were staff available. Another person began coughing in the communal lounge and staff did not respond to this in a timely manner. We had to alert staff members to this person needing support. Another person was shouting for staff support as another person was entering their bedroom uninvited. We had to ask staff to support with this situation. Staff members congregated in areas people were not using such as the dining room to complete daily records, leaving people alone in other areas of the service further increasing the risk of social isolation for people. Staff only spoke with people to support them with essential care needs such as needing a drink or checking if they needed personal care.

Processes were not in place to make sure staff training had been effective. Staff were not receiving competency checks in areas such as moving and handling, medication or IPC to make sure training had been effective and they were competent in these tasks. Staff were not having supervisions to discuss their practice and make improvements if this was necessary. The home manager did not have oversight of the training matrix despite the registered manager thinking this was the case. The oversight of training and moving and handling competencies were instead the responsibility of a staff member who was not primarily a care worker. This staff member told us they had trained to deliver moving and handling competencies however did not feel confident to carry out this role. This put people at risk as staff were not competent to complete these essential support tasks. When new staff joined the service, the provider was not ensuring all the necessary checks were completed to help ensure they were safe and suitable to support people living at the service. Staff checks were missing full employment histories which is a requirement when employing new staff and these were not in place.

People told us they felt the service was clean. One person said, ‘‘[Staff] seem to keep the home clean.’’ However, a relative explained, ‘‘The cleaning in the home could be better and we do bring our own wipes and clean the room as sometimes it isn’t as clean as it could be.’’ Despite people telling us they felt the service was clean, it was not and people were at risk from poor IPC practices. We discuss this further in the rest of this quality statement.

Staff were unable to explain to us what the systems in place were in relation to keeping the service clean and preventing IPC concerns. There was one staff member employed to keep the service clean, however they also helped night staff in the early hours of the morning to support people with breakfast. They told us they found it difficult to completely clean the service with the time they were given, particularly as the building was in disrepair in some areas. The management team were unaware of the IPC issues at the service and were surprised at our findings when we walked around the service with them. Effective audits were not being undertaken to help ensure the service was being kept clean and IPC measures taken by staff were effective.

People were not being protected from harm to possible IPC concerns as the service was not being kept clean. Multiple areas of the service including communal areas, people’s bedrooms and the dining room were visibly dirty with a build up of dust, dirt and cobwebs around the environment. The carpets in areas of the service had visible dirt and debris build up on them. Lampshades in corridors had multiple dead insects on them. In people’s bedrooms there was visible dirt and debris that had built up in areas of the rooms and the en-suites. The bathroom and shower rooms at the service were also visibly dirty with ingrained dirt and mould visible in many areas. The kitchen was not being kept clean and there were multiple stains and a build up of dirt and grime throughout the area. There were also food items in the fridge which were either out of date or had not been labelled to say when they were safe to use. There was a clinical waste bin left in a communal corridor which was being used to store clinical waste and this was accessible to people.

Processes were not in place to ensure the service was kept clean and free from IPC concerns. We asked to see evidence of daily checks completed by staff to show cleaning was happening but these were not available. The registered manager shared an IPC audit with us, however this had not identified the IPC concerns we identified at this assessment. Following our first site visit to the service we fed back our IPC concerns to the registered manager, On our return to the service 8 days later little action had been taken to clean the service and we found the same IPC concerns, indicating processes were ineffective.

People were at risk from unsafe medicine administrations practice. We observed staff administering medicines unsafely by dispensing multiple people’s medicines and carrying them around in one place to administer to people at the same time. Staff were not returning to sign and check the medicines given to people were correct. This put people at risk of having medicines incorrectly dispensed. We also observed staff placing medicines directly in to people’s mouths without washing their hands or wearing appropriate personal protective equipment (PPE), putting people at further risk. One person was being administered a medicine they were prescribed to take as and when required on a daily basis with no recorded rationale as to why this was. This medicine was supposed to only be used if the person was feeling upset and had the effect of making the person feel sleepy. This put the person at risk of being overdosed with this medicine. Another person was not administered some of their medicines for a period of 14 days as there were issues with the supply from the pharmacy. This had not been effectively addressed and put the person at risk of not receiving their medicines as prescribed. People’s topical medicines were left in unlocked cupboards in their bedrooms meaning they may be used unsafely by people.

Staff had training in medicines, however this was not being regularly checked to ensure staff were competent to administer them. Staff members who we observed following unsafe practices did not have competency checks recorded to ensure they were able to do this safely. Other staff members had competency checks however they were completed some time ago meaning they may not be as competent to administer medicines as they were before. The home manager and registered manager did not have a good oversight of medicines practice at the service. We fed back our concerns about medicines practice when we observed this happening however staff began to administer medicines again later in the day as the management team had not addressed these concerns with them.

Processes were not in place to manage medicines safely. Audits of medicines were completed to see if the correct amount of medicines were being administered to people. However, no audits were in place to monitor staff practice in this area or check to see if staff were competent in medicines administration. We found numerous missing staff signatures to show that people had been prescribed their medicines correctly. People who were prescribed medicines to be taken as and when required did not have detailed protocols in place to guide staff when these should be administered. This out them at risk of receiving these medicines incorrectly. People’s allergies to medicines were not recorded for use by the pharmacy to help ensure people’s medicines were safe for them to take.