Hillbrow Residential Care Home Limited

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Evidence showed incident reviews were routine, with monthly accident analysis identifying themes and required actions. The provider conducted route‑cause analysis and updated care plans where needed.

Records demonstrated learning from unwitnessed falls and timely communication with external professionals. Staff spoken with described feeling listened to and supported by managers.

People said staff responded promptly when they raised worries, one person said, “I spoke to the manager… now there’s no problem at all”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Systems supported safe assessment, care planning and transitions. Care plans were detailed and regularly reviewed, including risk assessments and multidisciplinary input. Staff followed clear pathways when health needs changed.

People described safe care and prompt responses to deterioration. For example, one relative said, “They called for the physio… the GP had made an urgent referral”. External professionals confirmed staff acted on clinical recommendations, such as speech and language therapy guidance for modified diets. One person noted “They [staff] always check my eyes and make my appointments”.

People said care and support plans reflected their needs and were reviewed with them and their families. Medicine reviews were completed during admission and following changes.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People felt safe and trusted staff. They consistently reported that staff treated them kindly and protected them from harm. One person said, “I felt absolutely safe… nobody bullied me or harmed me”. Staff used required equipment safely and people said they felt protected when supported with mobility or personal care.

Staff knew how to recognise and report safeguarding concerns, and relatives said they were confident the team managed risks well. Leaders investigated concerns promptly and acted when conduct issues were raised, including implementing staff performance plans where needed.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that the service was working within the principles of the MCA.

There were clear systems for supporting people who lacked capacity, with appropriate use of mental capacity assessments, best interest decisions and DoLS applications. Records showed regular involvement from families, GPs and external professionals to ensure decisions promoted people’s rights and welfare.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff involved people and their families in understanding and managing risks. People felt able to discuss concerns and said staff respected their choices.

Risk assessments were personalised, regularly reviewed and described the actions needed to keep people safe, including specialist advice. Families confirmed they were involved in planning, including best interest decisions. A relative explained how they were involved in important decisions on their family members behalf. They said, “a best interest decision was made… and they would not give medication covertly as a result.”

Staff worked with people to adjust support where risks changed, and people said staff were open and responsive to feedback.

We observed care being delivered in line with people’s care plans, which promoted their independence and choice.

The provider detected and controlled most potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The environment was clean, comfortable and well maintained, however there were gaps in oversight and checks which the provider took steps to improve during the inspection. There were missed fire safety checks. Fire escape route checks, fire alarm tests and fire door inspections had not been completed since 22 January 2026. Leaders acknowledged these issues and identified the need for better delegation during staff leave. Records also showed monthly room checks were inconsistent. While actions had been taken to ensure improvements were made, the oversight systems had not ensured all safety checks were completed as required.

Equipment and safety checks were carried out, such as water temperatures, gas and electrical safety were conducted appropriately. People told us they felt safe in the building.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

We observed staffing levels met people’s needs and people’s needs and requests were responded to without delay. Staff described workloads as manageable. People consistently praised staff, saying “They are wonderful… they do their very best”. Most people said staff responded within a few minutes when they rang the call bell, though some experienced waits of over 10 minutes at busy times. Internal records confirmed regular monitoring of call bell response times, averaging between 4 and 7 minutes.

The provider used a dependency tool to help determine the right staffing levels. Rotas showed the provider’s preferred staffing were generally maintained across the day and night, with additional staff added to the morning shift following feedback from the staff team. Staff told us staffing levels were good when there were no unplanned absences.

A competency-based induction supported new staff, and training compliance was good, with reminders issued before expiry dates. People said they felt staff were skilled, respectful and knew their needs well. On-going training ensured staff maintained the knowledge and skills required to deliver safe care.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Infection prevention arrangements were effective. The home was consistently clean, odour‑free and well maintained. Staff used protective equipment appropriately, and people said staff maintained good hygiene when providing care. One person said “They bring gloves and hand gel” when supporting catheter care.

Housekeeping staff followed good hygiene practices. Shared areas, including dining and lounge spaces, were visibly clean. Staff received training in food hygiene and infection control, and the kitchen achieved a 5-star food hygiene rating. People described the service as clean and comfortable, and visitors confirmed this was consistent.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines were managed safely. Medicines were stored securely, including controlled items and topical creams. The clinical room was secure, clean, and tidy.

People received their prescribed medicines in accordance with their needs. Records showed prompt action was taken on medicine changes following GP reviews. One person said their GP “reduced my medicines… she listened to me”. Staff followed guidance given by external professionals, for example, when preparing thickened fluids.

Staff completed competency assessments and followed clear protocols. People said staff explained medicines to them, and we heard staff explaining to 1 person, “This one’s for your thyroid.”

People confirmed staff supported them safely, and professionals reported the service followed recommendations reliably.