Hillsborough Residential Home

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• 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 that 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 good. At this assessment the rating has changed to 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 a legal regulation in relation to governance at the service.

This service scored 57 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

New staff were supported to provide care in line with organisational values. They completed an induction before starting work which included time to read people’s care plans and get to know their needs.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Staff told us there had not always been a positive culture but they felt things were improving and staff morale was getting better. The registered manager had left the service and cancelled their registration shortly before the inspection. At the time of the inspection a senior carer was overseeing the service with the support of the provider. They had no previous managerial experience. This was a short-term arrangement until a new manager could be recruited. They were honest and open during the inspection process, admitting the situation was ‘chaotic.’ Other staff were supportive of the arrangement and recognised the challenges. They told us; “[Name] is doing their best, we are all pulling together” and “Things are getting better now, it was a bit stressful when the manager left.” The provider was actively looking to recruit a new manager.

People did not always feel they could speak up and that their voice would be heard.

We had mixed feedback about speaking up. Some staff told us, in the past, they had not always felt listened to or valued. Others said they had opportunities to voice concerns. Staff meetings were organised. However, not all staff had received any one-to-one supervision meetings. These can provide an opportunity for staff to discuss any concerns they have.

The provider did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There was an Equality and Diversity policy. This stated reasonable adjustments could be made to support staff with a disability in the workplace. However, staff had not been asked to complete a health questionnaire when they were offered a contract so the provider may not have been aware of any hidden disabilities which needed to be taken into consideration.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Records were disorganised and difficult to locate. There were gaps in records. For example, there was no record of staff training available for inspection. We were unable to locate all the necessary health and safety records. Although a DoLS referral had been made we were unable to locate the paperwork and could only verify this by checking with the local DoLS team. Care plans referred to SALT assessments there was no evidence these had ever taken place and the local SALT team had no records of them. Since the manager had left, audits were not being completed.

The provider did not have effective oversight of the service. There was no formal system of reporting to enable them to monitor how the service was being managed. For example, themanager had not been required to submit regular manager reports. Manager audits were not reviewed. The provider told us any meetings or discussions between themselves and the manager had been informal and not recorded.

However, staff told us the atmosphere in the service had improved. A senior was focusing on improving systems and giving senior staff greater access to records to enable them to support the running of the service.

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.

External professionals did not raise any concerns about how the service worked with them. One commented; “Staff are always friendly, welcoming, knowledgeable about client’s needs.”

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. They did not always actively contribute to safe, effective practice and research.

There were no systems to drive improvement. We raised some concerns relating to safe recruitment and safeguarding. The provider told us they had looked into the issues raised. However, there was no documentation to evidence their investigations. We could not be assured investigations were thorough and took into account the experiences of all stakeholders.