Archived: Hill Farm

Hill Farm is a ‘care home’. People in care homes receive accommodation and nursing and personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service provides support for up to nine people with physical and learning disabilities. There were six people living at the service at the time of our inspection including people with sensory impairments, autism and behaviours which can challenge.

The service was run by a registered manager who was present at our visit. They were registered to manage this service and another small service in the local area which is registered with the same provider. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The service was last inspected on 3 August 2017 when the area of ‘Well-led’ was rated as ‘Inadequate’ and the overall rating was ‘Requires Improvement’. At that time we found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had failed to ensure that there were sufficient numbers of staff to keep people safe and that they were suitably trained: Regulation 18. There was also a continuous breach of Regulation 17 in that the provider had failed to assess, monitor and improve the quality and safety of the service and to mitigate risks.

The provider sent us a plan of action on 30 October 2017 setting out how they would improve the service to meet the Regulations.

We also made recommendations regarding following guidance in relation to making best interest decisions and reviews staffing deployment to ensure people have access to transportation as required.

At this inspection, on 16 and 20 April 2018, we found continuous breaches of Regulation 17 and 18. Quality assurance systems remained ineffective in highlighting shortfalls in the service or where shortfalls had been identified; they had not been addressed consistently or in a timely manner. Staffing levels had been increased since the last inspection in August 2017, but this had not been maintained. Staffing levels were increased back to safe levels on 20 April, but only as a direct result of our inspection visit. There remained shortfalls in staff training and support. We also found additional breaches of regulation with regards to the management of risks and inconsistency in treating people with dignity and respect.

This is the fourth time the service has been rated Requires Improvement.

The overall rating for this service is ‘Inadequate’ and the service is therefore placed in special measures.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

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

Staff had not always received the training or knowledge needed for their roles including how to support people with behaviours that challenged, with an epileptic seizure, to apply first aid and to move people safely. The registered manager booked a training day for staff on challenging behaviour and epilepsy after the inspection visit.

There was inconsistency in the assessment and management of risks which meant that guidance and practices were not always in place to minimise any risks identified to people. There were not effective systems in place to monitor accidents and incidents as some information which informed the provider had not been kept up to date.

Staff knew people well, had built positive relationships, understood their likes and dislikes and preferred methods of communication. One person had a staff team built around them which matched their cultural needs and had had a positive impact on them in the reduction in their behaviours. However, there were inconsistencies in staff practice in treating people with dignity and respect. Some staff spoke about people in their presence as though they were not there and there were occasions when staff did things for people rather than promoting their independence.

There were systems in place for the management, storage, disposal and administration of medicines. However, some people’s pain medicine was out of date so it was not available should it be required. We have made a recommendation about the management of medicines.

It was difficult to assess if people took part in a range of meaningful activities as records had been completed inconsistently. We made a recommendation about the recording of activities. Staffing levels had a direct impact on if people were able to spend time out in the community. On the first day of the inspection people took part in music for health but not everyone was able to go dancing. On the second day of the inspection, when staffing levels had increased, everyone went on a trip and lunch out to the seaside.

Staff were recruited safely and had completed an induction programme. Most staff felt supported but formal planned supervision sessions had not taken place in line with the provider’s policy. Three out of four night staff had not received a supervision or review of their competency for over a year and one of these staff’s probationary period had expired.

CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS applications had been made to ensure that people were only deprived of their liberty, when it had been assessed as lawful to do so. All interested parties were invited to best interest meetings in line with the principles of the e Mental Capacity Act 2005. However, there was inconsistent practice in gaining people’s consent before supporting people with their care. We have made a recommendation about this.

Staff knew about the signs and symptoms of abuse and how to raise a concern inside and outside the organisation.

Staff followed the provider’s guidance to help minimise the spread of any infection.

People’s health, social and physical needs were assessed and guidance was in place to ensure they were monitored and supported to access health care and advice as required. People were supported to have a variety of foods which met their health needs and cultural preferences.

People's care plans detailed people's needs and how they preferred to be supported. They included information about people's life history, likes and dislikes and who was important to them. They contained 'communication passports' and details about how people would let staff know if they were upset or in pain.

There were policies in place that identified that people would be listened to and treated fairly if they complained about the service.

There had been an improvement in staff morale as staff felt that as the service was being sold, a new provider would be more effective in making the necessary improvements.

We found two continued and two additional breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 at this inspection. You can see what action we told the provider to take at the back of the full version 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.

Hill Farm is located on the outskirts of Sittingbourne and provides care and support for up to nine people who have a range of physical and learning disabilities. People had sensory impairments, epilepsy, limited mobility, behaviours which can challenge and difficulties communicating. Accommodation is set out over two floors with lift access to the first floor. On the day of our inspection there were six people with learning disabilities living at the home.

Hill Farm had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the home. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the home is run.

At our previous inspection on 16 August 2016, we found breaches of Regulation in relation to managing risks to people and the provider’s monitoring systems. We also made recommendations about staff inductions, improving communication with relatives and displaying the service’s rating. At this inspection we found that some improvements had been implemented; however there was a continuing breach found in relation to the governance of the service. Risks to people had been assessed and plans were in place to guide staff how to minimise the risks. The monitoring systems, including a variety of audits had identified some issues and action had been taken to address some shortfalls in this area. However audits had not identified issues found at this inspection. Communication with people’s relatives had improved and we saw evidence of regular contact with people’s loved ones.

Staff told us that they could contact the registered manager for support but they did not always feel supported by them and the providers. Staff were able to give their opinion but stated that they were not always listened to and their ideas were dismissed. The providers planned to sell the service which had resulted in a period of uncertainty and a number of staff vacancies which appears to have led to low staff morale. Staff told us they did not always feel there were enough staff to support people and our observations confirmed this. The registered manager increased the staffing levels at the service after the inspection. There was a shortage of drivers which limited their staff’s to support people to go out. Staff tried to minimise the impact of this on people. We made a recommendation about this.

Staff were recruited safely and had an induction including the completion of the care certificate. The care certificate is an identified set of standards that social care workers work through, based on their competency. Staff completed basic training; however they did not have all the training required to meet people’s needs. The registered manager sent us information about this after the inspection.

The registered manager and staff understood how the Mental Capacity Act (MCA) 2005 was applied to ensure decisions made for people without the relevant mental capacity were only made in their best interests. The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS). The registered manager had applied for DoLS authorisations in line with the legislation. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way. The registered manager had not always included all interested parties in best interest decisions. We made a recommendation about this.

People were supported by staff who knew them well and understood their support needs. One person at the service had English as a second language. They were supported by staff who spoke their first language and understood their cultural needs. Some people preferred to be supported by staff that were the same gender as them and this was accommodated. People were involved in deciding which foods were on the menu. They were supported to have a variety of foods which met their health needs and cultural preferences.

Staff understood their role in keeping people safe. They could tell us the different types of abuse they may encounter and who they would raise any concerns to both inside and outside the organisation. People’s medicines were managed safely and in the way people preferred. People were supported to access health care as required and advice given by health professionals was followed.

People’s care plans detailed people’s needs and how they preferred to be supported. They included information about people’s life history, likes and dislikes and who was important to them. Care plans showed what people could do for themselves and how they liked staff to support them. They contained ‘communication passports’ and details about how people would let staff know if they were upset or in pain. People had access to a variety of activities based on their likes and dislikes. However, these could be limited by a lack of drivers and staff availability. People had access to activities in their garden which they appeared to enjoy.

The registered manager had worked with people with learning difficulties for a number of years. They were supported by the providers and administrative manager. They worked closely with local health professionals and service commissioners. The registered manager agreed they would benefit from attending local forums for registered managers to update their knowledge and awareness of good practice.

There was an accessible format of the provider’s complaints procedure in place. Monthly keyworker meetings were used to check if people were satisfied or dissatisfied with the service. No complaints had been received at the service in the last 12 months.

We found a continued breach and additional breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 at this inspection. You can see what action we told the provider to take at the back of the full version of this report. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Hill Farm is located on the outskirts of Sittingbourne and staff provided care and support for up to nine people who have a range of physical disabilities and learning disabilities. People had sensory impairments, epilepsy, limited mobility and difficulties communicating. Accommodation is set out over two floors with lift access to the first floor. On the day of our inspection there were seven people with learning disabilities living at the home.

Hill Farm had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the home. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the home is run.

At our previous inspection on 07 March 2016, we found breaches of Regulation 9, Regulation 17, Regulation 18 and Regulation 20A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider sent us information in June 2016 which evidenced that they had made some improvements to the service.

This inspection found that improvements had been made to care and support, activities, staff support and training. However, improvements to some areas were still required.

People were unable to verbally tell us about their experiences. Relatives gave us positive feedback about the service and the management of the home.

Risks to people’s safety had not always been adequately assessed and action taken to reduce the risks in relation to window safety. Some risk assessments had not been completed. Bathing risk assessments relating to risks of scalding when using baths and showers were not completed.

Medicines had been administered following the provider’s medicines policy and following good practice guidance. Medicines records were not always accurate and complete.

Systems were in place to enable the provider to assess, monitor and improve the quality and safety of the service, however these had not been fully embedded, which meant further improvements were required.

There were enough staff on duty to meet people’s needs. Recruitment practices were safe, relevant checks had been made to check that staff were suitable to work with people. Staff had undertaken training relevant to their roles. Staff had received regular supervision and support. Staff induction to new roles varied. We made a recommendation about this.

Staff had received training about protecting people from abuse and showed a good understanding of what their roles and responsibilities were in preventing abuse.

People enjoyed the food; meals were served according to people’s assessed needs. People helped to choose the food on the menu.

There were procedures in place and guidance was clear in relation to the Mental Capacity Act 2005 (MCA), which included steps that staff should take to comply with legal requirements. Staff had a good understanding of the MCA to enable them to protect people’s rights.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Deprivation of Liberty Safeguards (DoLS) applications had been made to the local authority and had been approved.

People received medical assistance from healthcare professionals when they needed it. Staff knew people well and recognised when people were not acting in their usual manner. The staff ensured people received effective, timely and responsive medical treatment when their health needs changed.

Interactions between people and staff were positive and caring. People responded well to staff and engaged with them in activities. People were encouraged to take part in activities that they enjoyed. People were supported to be as independent as possible.

People and their relatives had been involved with planning their own care. Staff treated people with dignity and respect. People’s information was treated confidentially and personal records were stored securely.

People’s view and experiences were sought during review meetings and key worker. Relatives were also encouraged to feedback through surveys.

People’s care plans had been reviewed and updated to ensure that their care and support needs were clear and their preferences were known. People were encouraged to take part in activities that they enjoyed, this included activities in the home and in the local community.

Communication between staff within the home was good. They were made aware of significant events and any changes in people’s behaviour.

The provider and registered manager had notified CQC about important events such Deprivation of Liberty Safeguards (DoLS) applications in a timely manner.

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.

Hill Farm is located on the outskirts of Sittingbourne and staff provide care and support for up to nine people who have a range of physical disabilities and learning disabilities. People had sensory impairments, epilepsy, limited mobility and difficulties communicating. Accommodation is set out over two floors with lift access to the first floor. On the day of our inspection there were seven people with learning disabilities living at the home.

Hill Farm had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the home. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the home is run.

At our previous inspection on 09 and 15 June 2015, we found breaches of Regulation 9, Regulation 10, Regulation 11, Regulation 12, Regulation 13, Regulation 14, Regulation 15, Regulation 17 and Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Regulation 18 of The Care Quality Commission (Registration) Regulations 2009. We took action against the provider.

The provider sent us information in September 2015 which evidenced that they had made some improvements to the service and had instructed help from an external consultant.

At the last comprehensive inspection this provider was placed into special measures by CQC. This inspection found that improvements had been made which had moved the overall rating from inadequate to requires improvement, which was enough improvement to take the provider out of special measures. However, improvements to some areas were still required. As a result, they were breaching regulations relating to fundamental standards of care.

Records relating to care and support provided were not accurate and complete. Systems were in place to enable the provider to assess, monitor and improve the quality and safety of the service, however these had not been fully embedded, which meant further improvements were required.

Staff training had improved, however further training was required to ensure staff had suitable training to meet people’s needs. Staff had not received regular supervision.

The provider had not displayed the rating from the last inspection so that people, relatives and visitors could see it.

People’s care plans had not been reviewed and updated to ensure that their care and support needs were clear and their preferences were known.

Medicines were accurately recorded and appropriately stored. Staff had not taken appropriate action to protect themselves from the risks of touching medicines. We made a recommendation about this.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Deprivation of Liberty Safeguards (DoLS) applications had been made to the local authority for some people, one had been missed. We made a recommendation about this.

Staff had received training about protecting people from abuse and showed a good understanding of what their roles and responsibilities were in preventing abuse.

People’s safety had been assessed and monitored.

Meals and mealtimes promoted people’s wellbeing, meal times were relaxed and people were given choices.

The provider had made improvements to the home which included creating a sensory room.

There were enough staff on duty to meet people’s needs. Staff said that they received good levels of support from the management team.

There were procedures in place and guidance was clear in relation to the Mental Capacity Act 2005 (MCA), which included steps that staff should take to comply with legal requirements. Staff had a good understanding of the MCA 2005 to enable them to protect people’s rights.

People were supported and helped to maintain their health and to access health services when they needed them.

People were encouraged to take part in activities that they enjoyed. People were supported to be as independent as possible.

Staff were positive about the support they received from the senior managers within the organisation. They felt they could raise concerns and they would be listened to.

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.

We set out to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people using the service, the staff supporting them and looking at records. If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

We found that the home was well presented and clean in all areas and there were reliable procedures in place for the ongoing cleanliness of the premises and equipment. Each bedroom in the home was personalised and each room looked bright and cheerful. One person who used the service told us they "Like my room".

The home did not have appropriate recruitment procedures in place to ensure that staff working in the home were of good character, that they were suitably skilled and qualified for their job roles.

We found that the home had a good system in place to check that agency staff were suitably skilled and trained to do the job.

People's needs were assessed and care and treatment was not always planned and delivered in line with their individual care plan. We found that the home did not have suitable arrangements in place to deal with foreseeable emergencies.

Records showed that the manager had not taken people's care needs into account when making decisions about the number of staff the home required daily. We observed that when incidents occurred it took three staff members to deal with the situation, which took care and support away from other people who lived in the home.

Records were not kept up to date. We found care plans and risk assessments with conflicting information.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to recruiting new staff and planning for foreseeable emergencies.

Is the service effective?

People's health and care needs had been assessed and care plans were in place. There was limited evidence of people being involved in assessments of their needs and planning their care particularly people who lacked capacity to give consent.

We saw that some best interests meetings had taken place for people who lived in the home. We saw that family members, staff and care managers were involved in these meetings. We found that the meetings did not always discuss the least restrictive solution to situations where people required medical treatment or support to keep them and others safe.

We have asked the provider to make improvements and meet the requirements of the law in relation to involving people in planning their care and consent to care and treatment.

Is the service caring?

Staff supported people to take part in planned activities. We saw that staff offered encouragement to dance, clap and to hold musical instruments during a music session. People who used the service appeared to be happy and got out of their seats to either dance, clap or to pick up new instruments during the activity.

People who used the service were supported to engage in activities outside of the home.

Staff told us that the management team was "Very understanding and helpful".

People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's needs and likes.

Is the service responsive?

People's views were not always listened to and taken into account in the ongoing management and monitoring of the home's progress. The provider did not always seek the views of people actively involved with people who lived in the home.

We looked at the likes and dislikes detailed in care plans for people that used the service. We saw that these were clear. We found that some preferences regarding likes and dislikes of food had not been communicated to the kitchen staff.

We have asked the provider to make improvements and meet the requirements of the law in relation to involving people in planning their care.

Is the service well-led?

The provider had effective systems to identify, assess and manage risks to people's health, safety and welfare.

We did not see any evidence that the provider met with people who used the service to gain feedback. We spoke to the manager about this, they told us that there had not been a meeting for a while and the home was due one. We also did not see that the provider met with staff.

We found that a range of audits had been undertaken by the service. These included monthly medication checks, monthly key worker reports and we saw that the home was checked twice a day to ensure that all areas were safe for people using the service. The audits had not picked up that people's care files had conflicting and inaccurate information in them.

We have asked the provider to tell us what improvements that will make in relation to improving the auditing arrangements, staff training and gaining feedback from people who use the service.

We checked standards of cleanliness at the service and found bedrooms and communal areas to be clean and tidy. However the laundry room was not being operated in such a way as to reduce the risks of cross-contamination or the spread of infection.

Appropriate checks had not been undertaken before staff began work at the service. We found that an agency worker had no previous experience of working with people with learning disabilities and that recruitment files did not contain adequate information about staff.

We saw evidence that staff had received increased training and that a full programme of courses had been scheduled. An external training provider had been engaged by the service.

The views of people, staff and relatives had been sought for the purposes of making improvements to the service. We saw that the service had sought the opinions of people and their relatives by way of regular surveys. You can see our judgements on the front page of this report.

We found that people were given care and support in a respectable and kind manner. They received enough food and drink throughout the day and were able to request more if they wished. People were safe and their medication was given to them in a way which ensured their welfare. Staff had not received enough training to ensure that people were cared for in an appropriate way at all times.