Hillsborough 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 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 requires improvement. We identified breaches in relation to the governance of the service.At this assessment we found the breach of regulations had been met, the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.
 

This service scored 75 (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.

The manager was working to improve the culture of the service and develop better processes for communication. Staff told us morale had improved. Daily handovers and meetings enabled the manager to keep all staff updated about people’s needs, staff responsibilities and expectations.
 

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The manager had worked with external agencies and staff to identify areas for improvement and implement changes. Staff were positive about the changes and told us they were well supported and able to approach the manager at any time with queries or suggestions. The manager was in the process of applying to be registered with CQC.
People and their relatives were also positive about management. Comments included; “The new manager is approachable and organised” and “Things are getting sorted. They needed someone to make decisions.”
A deputy manager worked alongside the manager and each had clear areas of responsibility. Both told us the relationship was mutually supportive. The deputy manager was working towards a Level 5 qualification with the support of the manager.
 

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they felt able to raise concerns or ask questions at any time. Staff meetings were held regularly. The manager had plans to move their office to a more central position within the service so they would be more visible to people, staff and visitors.
 

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.

A member of staff from overseas told us they had not experienced any discrimination at work and were treated fairly. When staff had encountered negative and discriminatory remarks from people using the service because of their race or gender, the manager had taken steps to help ensure staff were protected.
 

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The manager had completed audits of some areas of the service and had plans to do others until all aspects of the service had been reviewed. Where shortfalls had been identified these were addressed promptly. For example, audits had led to changes to the way medicines were managed and processes for using agency staff had been adapted to ensure they had the required skills.
Any shortfalls identified during the inspection were also addressed promptly. For example, a supervision matrix was developed and information relating to staff competency checks included to give a clear oversight of staff support systems.
Accidents and incidents were recorded with detail included to enable managers to identify any patterns. Where needed, information was shared with external agencies.
 

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.

We saw evidence external health care professionals were involved in people’s care. For example, GP’s and district nurses. The new manager had also worked with the local authority quality team to identify where improvements were needed and take appropriate action.
Staff knew how to contact external professionals and make relevant referrals to help meet people’s changing and ongoing needs.
 

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The manager was keen to improve the service. They told us, “We have worked hard to get the home to where it is now.” As well as identifying where improvements were needed to existing processes, they were keen to introduce new systems and ideas to develop the service further.