Hillsborough 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 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 changed to 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 service was in breach of legal regulations in relation to safe care and treatment, the way in which people’s medicines were managed, safe recruitment and governance at the service.

This service scored 53 (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. Staff did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

We were not assured processes for investigating safeguarding concerns and incidents were robust. During the inspection process we were made aware of potential safeguarding incidents which we shared with the provider. They subsequently informed us they had looked into the events and found the concerns were not founded. However, there was no record of what action had been taken in response to the concerns.

Staff described the action they would take following an incident or accident. Any falls were recorded as an incident in people’s records. Some of these records lacked detail. For example, one record stated the person had fallen at the top of the stairs. There was no information about the circumstances of the fall or exactly where it had taken place. A member of staff, who had been present at the time of the incident, was able to clarify which stairway was being referenced and that the person had fallen when getting out of the stair lift. The failure to record this detail meant opportunities to learn from the incident, identify any patterns or trends and mitigate further risk may have been missed.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Pre-admission assessments were completed before people moved into the service to help ensure the service was aware of people’s care needs and any identified risks. However, we found one person, who had moved in recently, did not have complete care plans or risk assessments.

Summaries of people’s needs were available for first responders if people had to be admitted to hospital unexpectedly. These were kept in the office which was not always accessible to staff. A senior member of staff told us they were changing the arrangements so staff would always be able to access information if needed.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Staff told us they had completed safeguarding training and that they understood their responsibilities. However, concerns had been raised recently by a relative to staff and no action taken. We shared the information with the local safeguarding team.

We were also told of a recent occasion when a resident had complained about how they had been supported. This had been investigated and discussed with the staff involved. There were no records of the incident or subsequent actions, the event had not been notified to the local safeguarding team or CQC. A senior member of staff told us they would submit the referral and notification retrospectively.

People and their relatives had no concerns about safety at Hillsborough. One told us they could leave their relative in the care home and feel confident they were well looked after. Comments included; “I’m confident they are cared for and “[Relative] is safe there, they manage the risk of them falling well."

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.

One person had a medical device fitted. The care plan stated there was a risk assessment relating to this in their room. This assessment was not in their room and could not be located. A member of staff told us they had not seen it and did not know how the device worked.

People’s health conditions meant they could sometimes become distressed and confused; they required additional reassurance at these times. A member of staff explained how they were able to help one person become calmer by singing a particular song with them. This information was not captured in care plans or risk assessments. This meant staff less familiar with the person did not have the information they needed to provide person-centred support when people were anxious.

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.

External contractors completed checks of equipment and the environment. However, the records to evidence these had occurred as required were disorganised. The provider was unable to locate any record of an electrical report. There was some evidence of portable electrical equipment being tested in February 2024, but we could not find recent records. Although staff could not find a Legionella certificate, we saw a letter confirming the testing had been completed with no concerns. There was a satisfactory gas safety report. We saw evidence chair lifts had been serviced at regular interviews.

Staff completed fire training and fire drills were completed. Fire officers had completed an inspection and identified some areas which required action. These had been completed.

Personal Emergency Evacuation Plans (PEEPs) had been developed and were conveniently located. A grab bag for use in an emergency was kept in a shed. Not all staff were aware where it was.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Processes to support safe recruitment had not been followed. One member of staff had received a reference containing negative information. This had not been followed up at interview and no risk assessment had been developed. We could not be assured the person was suitable for the role. Not all staff files contained photographic ID or full employment histories, new employees had not been asked to complete health questionnaires; these are information requirements as set out in Schedule 3 of the regulations.

There was no record of staff training to enable managers to identify gaps in training or highlight when training needed to be refreshed. Some people had specific medical conditions. Staff had not completed training in these areas. The service contacted the external training provider during the inspection visit, to request these areas were added to the list of required training. Relatives did not have any concerns about staff skills and competency.

During the day there were enough staff to support people in line with their identified needs. The provider had recognised the home was particularly busy at certain times of the day and had put an additional member of staff on the rota at these times. Overnight there were 2 members of staff on duty. Some people required support from 2 members of staff to support them with mobility. This meant there was no-one else available to respond to call bells at these times.

Staff told us they received regular supervision, however we did not see any records of supervision meetings.

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.

The service employed a housekeeper and 2 domestic staff. Apart from 2 Saturdays a month, a cleaner was on duty every day. The premises were clean and there were no malodours. There were cleaning schedules for all areas of the premises. These covered routine daily cleans and regular deep cleans. There were ample supplies of cleaning products and Personal Protective Equipment (PPE). The laundry and cleaning product cupboards were well-organised. Relatives told us they found Hillsborough was consistently clean and tidy although some described the décor as ‘tired.’

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Medicines were not always stored securely. The medicines fridge was unlocked and in a residents’ lounge area. This was moved to the senior staff office during the inspection. Regular checks of medicines needing extra security were not being undertaken. Storage temperatures were monitored. However, the full temperature range in the fridge was not recorded to show that these medicines were always kept at suitable temperatures.

There were improvements needed to people’s medicines record charts. When handwritten entries were made these were not always checked and signed by 2 members of staff to reduce the risk of errors being made. People’s allergies were not always recorded. There was a gap on one person’s chart where a dose had not been signed as given or a reason recorded as to why it had not been administered. Daily counts of doses were recorded. However, on someoccasions these did not match with the expected count. This meant it was not possible to be sure that people always received their medicines in the way prescribed for them.

Medicines care plans lacked full information for some medicines including blood thinning medication and flammable topical preparations, to show that people’s individual risks had been considered.

There was no suitable audit system to enable these issues to be identified and addressed.

However, people received their medicines in a safe way, taking time to make sure they were taken properly. One person told us they were happy with the way they received their medicines. Staff had completed training and competency checks.

There were suitable arrangements for ordering and disposal of medicines.

Protocols had been developed for medicines to be given ‘when required’, and times of administration were recorded. When external preparations such as creams were prescribed there were suitable systems for recording these.