Hillgrove Residential 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

Safe – this means we looked for evidence people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was in breach of legal regulation 12 in relation to people’s safe care and treatment, safe environments and staff training.

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.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice. Systems were in place for the analysis of accidents and incidents; however, although the provider had completed some audits we found they were not effective for issues identified by the inspection team. For example, the provider used equipment such as pressure relieving mattresses and sensor mats for people at risk of poor skin integrity or falls. We saw all the pressure relieving mattresses were not at the correct setting and the provider had not identified this as a concern and did not have awareness how this could be changed until the inspection team highlighted the issue. This placed people at the risk of avoidable harm. People and relatives told us they could contact the service if they had any concerns about their care.

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. Pre-assessment processes and documentation enabled a smooth transition into Hillgrove Residential Home. We saw evidence of referrals to relevant professionals when required. For example, dietitian and speech and language services. Staff demonstrated they knew people well and understood their needs.

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. Observations showed people were happy and felt safe in the company of staff. Peoples loved ones were confident if they raised concerns with the provider appropriate action would be taken. Peoples loved ones told us, “Very safe and I can speak to anyone, and they would help us. They are very kind and caring and listen to us all” and “They keep me informed of any changes and how [relative] has been, nothing is too much of a bother.” Staff were aware of the safeguarding procedures and knew how and when to raise a safeguarding concern.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Whilst risks to people’s personal safety had been assessed, some care plans did not always record the care needed to minimise these risks and keep people safe. Risk assessments and care plans in place were not always detailed around some preferences. For example, we found for one person in ‘what is important to me’ section said sleep was important and we could not find any reasons to explain why sleep was so significant to this person. This can be a risk as the care plan did not state if strategies or sleep schedules were in place to enable quality sleep to support a healthier life. We noted some bedrooms with sticky floors, and we concluded this was an overuse of cleaning products. This can be a risk to people who have issues with their mobility. We raised this with the provider and deputy manager.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. We found fire doors being propped open specifically in the basement. This included the storage area for hazardous products which would fall under the Control of Substances Hazardous to Health (COSHH) storage requirements. This created a risk in the event of a fire. Other doors were also propped open within the basement area which posed a fire risk including the laundry room, storeroom and storage room in the kitchen. Actions from recent fire risk assessment identified a series of improvements however, we found some actions were still outstanding and had not been completed within the recommended timeframe.

The provider was not always aware of their responsibilities to have fully trained staff delivering care. We found the provider was providing care and support to people at the service without any recent mandatory training such as manual handling or fire safety. The provider did not complete care records, and we found no evidence they had reviewed or read anyone’s risk assessments. We did see staff recruitment processes were in place with relevant checks of staff’s employment history, character, right to work, and checks with the disclosure and barring service (DBS). Staff we spoke with were very committed and passionate about the work they did at Hillgrove Residential Home. Most staff had completed their mandatory training and had their competencies assessed when required. Some staff still needed to complete some mandatory training including, fire safety, safe administration of medicines and safeguarding vulnerable adults.

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. People were protected as much as possible from the risk of infection because premises and equipment were kept clean and hygienic. People received support to maintain their own personal hygiene in line with their needs and preferences. Overall, the feedback about the cleanliness was positive and some comments included, “Had some improvements it is clean, her room is always clean and the corridors are clean, looked after outside, looks nice and clean and tidy in there, toilets are clean” and “Clean and a bit old, things are beginning to look better.”

Overall, the provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. However, we found in one person’s bedside cabinet there to be two prescribed creams for two different people and the cabinet was unlocked. We highlighted this with the provider, and they sought to resolve this immediately. Staff responsible for medicine administration had their competency levels regularly checked however we found 57% of staff had completed the yearly safe administration of medication training.