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 requires improvement. We identified breaches of regulations in relation to safe care and treatment, the way in which people’s medicines were managed, safe recruitment and governance at the service.At this assessment the service was no longer in breach of regulations and the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 63 (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.

Following our previous inspection the provider had taken steps to make improvements at Hillsborough. A new manager had been appointed, they were introducing systems and processes to drive improvements and monitor the service more effectively. Staff were more confident about when and how to raise concerns.

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.

Hospital passports were available to inform first responders and hospital staff of people’s needs if they needed to be admitted to hospital in an emergency. Not all the hospital passports had been recently reviewed so we could not be confident they contained the most up to date information. The deputy manager said they would review and update these records.
 

The provider had not always ensured people were supported in line with the Mental Capacity Act. Capacity assessments had not been consistently completed when required. However, 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 ensuring their safety. The provider shared concerns quickly and appropriately.

The service was now reporting any safeguarding concerns to the local authority and CQC as required. Any concerns raised were recorded and investigated. Staff were able to describe how they would raise any issues and were confident they would be dealt with by the manager. One person told us, “I feel safe, they do regular welfare checks on me.”
People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. We found DoLS applications had been made appropriately. However, capacity assessments had not been completed prior to the applications being made. The manager took immediate steps to address this.

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.

People told us staff were aware of any risks and acted to minimise this. Comments included; “I’ve been diabetic for 68 years and looked after myself. The staff here are managing it well. It’s a bit high today but they generally keep it under control” and “Staff would notice if I was unwell. They noticed immediately when I was under the weather. I’m a very private person and didn’t tell them I was unwell.”
Risk assessments identified when people were at risk and how staff could support people to stay safe while maintaining their independence as much as possible. We found some care plans had not been updated when new risks were identified. We raised this with the manager who assured us they would complete a review of all care plans.
Personal Emergency Evacuation Plans (PEEPs) had been developed to inform first responders and staff of the support people would need in the event of an emergency.
 

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

The premises were well maintained and regular safety checks were completed. Checks related to fire safety were completed including checks of emergency lighting and fire alarms. A grab bag was now kept in an easily accessible location which staff were aware of.

The housekeeper regularly ran taps in unused rooms to mitigate the risk of Legionella bacteria developing. However, these checks were not recorded. The manager told us they would make sure this was completed in the future.
 

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.

There were enough staff available to meet people’s needs. Since our previous inspection the use of agency staff had decreased meaning people were supported by staff who knew them well. Staff responded quickly to any requests for support and spent time chatting to people. We received good feedback about staffing levels from people and relatives, some of whom commented on the drop in reliance on agency staff.
Staff completed training relevant to their role when they started work at Hillsborough. Not all training had been refreshed as required. The manager was aware of this and was making arrangements for all staff to update their training.
Improvements had been made to the recruitment process. Prospective staff went through a series of background checks which included their right to work in the UK and their fitness for the role. All staff had undergone a Disclosure and Barring Service (DBS) check to help ensure they were suitable to work in the care sector. The manager was completing an audit of staff recruitment files to check for any gaps in the records.

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 premises were clean and well maintained. One person told us, “My sons visit when they can and they always comment on how clean the service is and how it always looks freshly hoovered with no smells.” Cleaning schedules were followed to help ensure all areas of the service were cleaned regularly, including deep cleans. Staff had access to personal protective equipment such as aprons and gloves to wear when providing personal care. Laundry was separated into coloured bags to mitigate the risk of cross infection.

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.

There had been improvements to the way medicines were manged. People received their medicines safely and as prescribed. This included creams and other external preparations. Staff were trained, and had competency checks to help ensure they were able to administer medicines safely.
We observed medicines being given in a safe and person-centred way. People were asked if they needed any medicines prescribed for use ‘when required’ such as painkillers.
There were still some further improvements to be made, however managers started to make the necessary changes during the inspection visit. These included improvements to the security of medicines stored in a fridge, temperature monitoring of the fridge, guidance for staff to refer to when administering ‘when required’ medicines and recording of patch application.
There were suitable arrangements for ordering and disposal of medicines, including improved arrangements for medicines requiring extra security.
Records showed staff were aware of risks with some medicines such as flammable topical preparations. However, risk assessments had not been developed for anticoagulant blood thinning medicines. Managers told us this would be addressed as soon as possible.
Medicines policies were being updated and improved to provide guidance for staff. Regular medicines audits now took place to identify where improvements were needed, actions were taken and recorded.