Hillgrove Residential Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation 17 good governance.

This service scored 61 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. In the provider’s strategy and vision, it stated they wanted to establish a high and consistent level of staff skills and training, however, the provider, who delivered care to people had not included themselves in key training.

Not all leaders understood the context in which the provider delivered care, treatment and support. The provider did not consistently demonstrate a full understanding of their role and whilst they were open and honest throughout the assessment and acknowledged that improvements were necessary, the provider did not maintain sufficient oversight of the service. The lack of effective governance meant that people did not always receive care and support that promoted their wellbeing or protected them from harm.

The provider had a positive culture where people felt they could speak up and their voice would be heard. Staff were encouraged to share their views during team meetings, supervisions and staff surveys. Peoples loved ones told us, “I can phone and speak to the deputy manager about anything and [deputy manager] is great to me” and “They encourage us to feedback. There is a survey once a year.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. There were policies and procedures in place to ensure the provider met their legal obligations to staff and work towards a fair and inclusive culture. Minutes of team meetings evidenced staff were invited to give feedback about the service.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. The provider had systems and processes in place to manage the quality of the service. However, we found quality assurance audits were often done but no record of these was completed or detailed. Regular management walk arounds, audits and quality checks were not completed consistently. The inconsistent approach to quality monitoring and governance resulted in poor oversight of care and support. The provider had developed new governance documents which were in the process of being implemented and reviewed. These new governance systems needed to be embedded, reviewed and sustained by the new management team.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The provider and staff had built a good relationship with local community teams and GPs to help support the service. Appropriate referrals were made to local authorities for support, where needed.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. Audits did not always highlight recurring themes or trends, and there were no proactive plans in place to mitigate risks to people's wellbeing. The provider had recognised their governance systems needed to be strengthened within the care home.