Hill House - Care Home with Nursing Physical Disabilities

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 regulation in relation to safe care and treatment.

This service scored 50 (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 based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Learning from incidents was not always embedded within the service. Incidents were not always reported by staff, nor consistently documented or analysed to identify trends and themes. Some accidents and incidents had been recorded and reported, however, actions to reduce the risk of reoccurrence were not always taken. For example, care records were not consistently updated following incidents to reflect changes in risk or support needs.

Staff told us some people could express distress verbally or physically; however, this was not always reflected in care records, and clear guidance on how staff should respond was not consistently available. Incident forms lacked sufficient detail, which reduced opportunities to fully understand events and apply learning. As a result, staff did not always have the information needed to respond safely and confidently. The service had missed opportunities to embed learning, strengthen reflective practice, and improve outcomes for people. One staff member told us, "I don’t know how to report an incident, and I have never been shown."

Following feedback, the manager took immediate action by implementing a tracker to monitor future incidents and advised they would review processes to improve oversight and learning. For example, by adding lessons learned to incident forms. The manager had also identified staff required further development on incident reporting and began rolling out training.

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.

Systems were in place to support safe transitions to and from the service. When external referrals were required, these were completed promptly, and healthcare professionals confirmed they were made in a timely manner. Staff told us they became familiar with people’s needs through structured handover meetings and by accessing the provider’s electronic care planning systems. Information required for hospital admissions could be accessed and printed without delay, supporting continuity of care. The provider was also exploring the introduction of hospital passports for people who may require them, to further enhance the safety and effectiveness of transitions between services.

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.

Safeguarding concerns had been raised by external healthcare professionals which had not been identified or proactively reported by the provider, indicating potential gaps in internal oversight. However, staff consistently reported they had received safeguarding training and demonstrated awareness of how to recognise and respond to signs of abuse. Feedback from relatives was mixed. Some expressed confidence that their loved ones were safe and well cared for whilst others highlighted previous concerns. One relative commented, “Hill House definitely requires some improvement.” The manager had implemented new systems to ensure safeguarding and incident reporting were clearly prioritised, reflecting a more robust and proactive approach. Relatives also reported increased reassurance following the appointment of the new management team, suggesting improvements were being made in the oversight and delivery of care. Where required, appropriate applications to deprive the person of their liberty under the Deprivation of Liberty Safeguards (DoLS) had been made. A monitoring system had been recently implemented to ensure DoLS were reviewed on a regular basis.

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.

Known fire risks associated with oxygen use and paraffin-based creams had not been fully assessed or documented, as this was absent in both risk assessments and individual personal emergency evacuation plans (PEEPs). Other aspects of risk was generally reflected within care plans, however some lacked detailed information or did not include clear signposting to additional information which could further support individuals’ needs.

Modified diets were prepared to the appropriate consistency and were presented in an appetising manner. Food was served by staff who checked meals prior to serving to ensure they met individuals’ dietary requirements.

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.

We observed that mobility scooters were being charged within a communal area which also served as a space with multiple exit routes. Although we were informed this area was used for charging overnight as a safety precaution, we saw scooters being charged during the day which did not give a homely feel. This practice also presented potential risks in the event of a fire, including obstruction of escape routes and increased fire hazards associated with battery charging. Most staff had received training in fire evacuation procedures; however, this had not been extended to night staff. Specialist medical devices required for respiratory and nutritional support did not always have appropriate checks in place to ensure the equipment remained safe and suitable for use. The manager immediately put these checks in place and assured us a more suitable solution would be found for charging mobility scooters.

The provider had all the required health and safety certificates and manual handling equipment checks in place. Maintenance repairs were reportable via a QR code.
 

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.

Relatives provided mixed feedback regarding staffing. Some relatives told us that not all staff were consistently knowledgeable about their loved ones’ individual needs, although they also stated staff really cared for their loved ones and complimented many staff individually by name. Relatives also reported a recent high use of agency staff, which may have impacted the continuity of care provided. One relative told us, "There is no proper staffing, it is all agency staff." Recruitment practices were not consistently robust, and we identified missing records and gaps within some staff files.

The manager responded positively to the concerns raised and demonstrated a willingness to take appropriate action. They also confirmed that the use of agency staff was reducing in line with ongoing successful recruitment and had recently commenced monitoring call bells times. Training records showed that most mandatory training had been completed. However, some staff competencies, particularly in complex clinical areas, were still in progress. The provider demonstrated due diligence in ensuring staff achieved a high level of competency before being signed off as competent. During the assessment, we observed staff to be visible in communal areas and actively engaging with people, offering reassurance and support.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Some concerns were identified which did not always support effective infection prevention and control (IPC). We observed some wheelchairs were dirty and the surfaces of bed bumpers were cracked, increasing the risk of cross-contamination and increasing infection risk. Some areas required a deeper clean. Staff fed back there had been a reduction in domestic staff and confirmed some cleaning tasks did not get done as a direct result of this. One staff member said they had raised this previously with their manager, however, no action had been taken. Regular IPC audits were carried out which had previously identified, back in September 2025, that there was no cleaning schedule for equipment. This was still not in place at the time of our assessment.

Despite these concerns, overall, the home was clean, staff had sufficient personal protective equipment (PPE) and had completed training. The manager reacted positively to our feedback and commenced looking into increasing staffing levels and introducing a robust cleaning schedule for equipment.

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

We identified several concerns in relation to medicines management. Fridge temperatures had been consistently recorded above the recommended range for over a month without appropriate escalation or documentation. This placed temperature-sensitive medicines, including insulin, at risk. Medicines and nutritional feeds were not consistently labelled with date-opened information, increasing the risk of use beyond recommended timeframes.

Stock management processes were inconsistent. We found expired medicines still in storage and stock checks were not completed regularly. In addition, the service experienced ongoing issues with obtaining medicines in a timely way from the pharmacy, resulting in the need to chase interim supplies and a risk of missed doses. There were gaps in recording and monitoring. Allergy information was recorded; however, details of reactions were not always included. We saw examples where injection sites were not routinely rotated, which could impact the effectiveness of treatment.

Medicines incidents were recorded, however, systems for escalating risks and managing national safety alerts were not yet fully embedded. Audits had been introduced and had begun to identify some of the issues found during inspection, although they had not yet fully captured all risks, including those relating to temperature monitoring.