Hillbeck Residential Care 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 Inadequate. At this assessment the rating has remained Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people being safeguarded from abuse, people’s safe care and treatment, the ways people’s medicines were managed safely, the competences of staff, and the lack of learning from incidents.

This service scored 31 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate safety events appropriately. Lessons were not learnt to continually identify and embed good practice.

Whilst there had been a reduction in falls since the last assessment, there still remained a lack of analysis of themes and trends around falls. For example, according to the incident reports, unwitnessed falls at night had reduced from March 2025 to June 2025 to approximately 3 per month. However, in July 2025 this had increased again to 8 unwitnessed falls. The registered manager told us they did not undertake an overall analysis of these to determine why there had been an increase. They said, “Themes and trends are done as and when individual ones (for individual people).” This meant they missed opportunities to put in place necessary action to reduce further incidents and prevent avoidable harm or risk of harm to people.

In addition, we noted from incident reports there had been 24 incidents of skin tears relating to 8 people since April 2025. Whilst 10 of the incidents related to 1 person and their distressed behaviours during personal care, there had been no overall analysis to determine the possible cause including whether it related to how people were being supported with moving and handling. This was despite a further incident to a person in May 2025 where it was determined that a bruise found on their leg could have been as a result of the moving and handling equipment.

The leaders did not make sure there was continuity of care, including when people moved between different services. Whilst the leadership team had undertaken assessments of people’s needs before they moved into the service, these were not always detailed and did not always provide guidance for staff on how to support people in a safe way.

We saw that a pre-assessment of 1 person’s needs had been undertaken by the registered manager in the person’s family home. This assessment lacked important information around the person’s health and care needs. The assessment stated the person had no history of falls. However, when the registered manager created their care plan, they stated there was a history of falls. Accurate information also had not been gained around the person’s health diagnosis. Knowing a person's full needs is crucial before they move into a care home to ensure they receive the appropriate level of care and support, tailored to their individual requirements. It is also important to determine whether or not the service could fully meet the person’s needs. This was not undertaken which placed the person and others at risk of harm as staff were not provided with the most accurate information around the person.

Another person had recently left the service as the registered manager told us they were no longer able to meet their needs. The registered manager told us this was because of the person’s distressed behaviours. However, when we reviewed the person’s incident forms, there was a lack of information recorded by staff on whether they were following the strategies that were in place in their care plan. It was not clear therefore, how or why leaders assessed that the person was no longer able to stay at Hillbeck.

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

At the previous inspection we identified people had been subject to abuse and neglect particularly at night. Whilst action had been taken by the provider to address this, there still remained a lack of robust management of safeguarding incidents. We identified from care records that 2 people had alleged they had been physically and emotionally harmed by another person that lived at the service. Despite the registered manager telling us they were aware of the allegation; they had not reported this as a safeguarding concern. They told us they would only report this if there had been a mark on the victim or long term emotional harm. They did not consider the impact of physical, psychological and emotional abuse. This lack of recognition of what constitutes alleged abuse meant that people were being placed at risk of further abuse.

We also identified from another incident report that 1 person had been found with a bruise to their neck. This had not been investigated to determine the cause of the bruise or reported to the local authority safeguarding team. Although staff were able to tell us what constituted abuse, they were not always reporting their concerns. One member of staff told us they had observed a member of staff being verbally abusive to people. However, they told us they would report it if they were to observe this again. They said, “If I witness it again, I will go to (Registered Manager).” We raised this the registered manager.

However, there were relatives that felt their loved ones were looked after well. Comments included, “I’m really happy with it, she’s safe, looked after and secure” and “I’ve never witnessed anything concerning, I would have pulled her out.”

The provider did not work well with people to understand and manage risks. The risks associated with people’s care were not managed in a safe way placing people at risk of harm. The management of the risks of people’s constipation was not managed in a safe way. There was a lack of guidance for staff in people’s care plans on how to reduce this risk.

As at the last assessment, where people required to have their fluid monitored, there were no targets set to ensure people were meeting these. The registered manager told us, “We aim for well over 1000 mls each day”, however they were not able to say how they arrived at this figure. We noted there were people that were not always reaching this target and there was a lack of evidence of how this was being addressed.

There still remained a lack of robust oversight of the risks of malnutrition. Leaders told us people were still only being weighed monthly regardless of how much weight they had lost. In addition, leaders were only looking at weight charts once a month. This means there still remained missed opportunities to take immediate actions where malnutrition was occurring. We noted that 1 person, according to the weight charts, had lost 17kg in a month between July and August 2025. We raised this with the registered manager who later told us the person had now been weighed again, and the weight loss had been incorrectly recorded for August 2025. However, this lack of oversight placed people at risk.

The behaviour support plans in place for people still did not always have sufficient guidance for staff on how to support people when they had incidents of distress. There was a lack of information on what may trigger people or how staff needed to respond when the person was directing their anxiety towards people and staff. This placed the person, staff and others at risk of harm.

However, since the last assessment, there had been improvements around the support people received with their oral health care. There was also clearer guidance in care plans around how to support people that had reduced mobility. Staff we spoke with were knowledgeable about the risks associated with people’s care including signs to look out for should a person with diabetes have high or low blood sugar levels. One told us, “Someone with diabetes may feel more sluggish or frailer.”

Staff told us they raised concerns if they felt people’s health was declining, One told us, “We get to know people’s ‘normal’ self’ so when they are out of sorts, we know they may not be well and tell a senior and record what we see onto the system.” Where people required to be repositioned in bed, we saw from records this was taking place. One member of staff told us, “The care plan has their repositioning chart and the process to follow, for example, what time to move them and onto which side, what equipment they need, their sling size and the number of staff needed."

The provider had detected and controlled potential environmental risks in the service for the most part. However, we noted there was no follow up to concerning actions identified from a nighttime fire drill. We saw from a fire drill undertaken in July 2025, that 2 staff were unsure of the actions they needed to take and were unsure of whether they had fire safety training. We saw from the training matrix that neither staff had refresher fire safety training as a result of this.

In addition, we noted the first aid box in the reception area had 3 items out of date including eye pads and a bandage.

Other safety checks of the environment were taking place frequently including moving and handling equipment, water temperature checks, legionella checks and window restrictors checks. All people had an up to date Personal Evacuation Plan in the event of an emergency such as a fire.

The provider did not make sure there were enough qualified, skilled and experienced staff. Leaders did not always make sure staff received effective support, supervision and development.

Where staff had been challenged on their moving and handling practices, action had not always been taken to ensure they received refresher training. There was 1 person that had been prescribed an epi pen (in the event they had an allergic reaction). However, staff we spoke with told us they had not been trained in how to administer this. Although the registered manager told us all staff had been trained, they were unable to provide evidence of this. The registered manager was also unable to tell us how to accurately administer the epi pen if it was needed. Although staff had received other mandatory training, this was not always effectively understood by staff to demonstrate their learning.

Supervisions were also not effective in identifying shortfalls. We found senior leaders and senior care staff at the service had not had robust oversight of people’s health care needs. There were shortfalls around the oversight of medicines, people’s continence and nutrition needs. This had not been addressed through supervisions. Where new staff had started at the service, the registered manager told us they required a supervision within 4 weeks of their start date. However, we identified this was not always taking place. New care staff require regular supervision to ensure they are undertaking safe and effective practice through their probational period.

Whilst we did not identify that there were not sufficient staff on duty both at night and during the day, staff fed back that at times the staff levels were not sufficient. Comments included, “We get by on a good day, if everyone is in and people are well”, “There are not enough staff, especially upstairs, because 2 residents have recently had hip operations so require more time and support then they did” and “We need at least one extra person because the level of some people’s dependency has increased.”

However, at the previous assessment, we found staff at night were not deployed effectively around the building. At this assessment we found this had improved. When we arrived at the service at 05.15am, there were staff on all floors instead of all congregated together. Care records also showed there had been an improvement around staff checking people regularly at night. We observed staff’s interaction with people living with dementia had improved. There was a better understanding of the needs of people living with dementia.

As at the previous assessment, for the most part, the leaders had assessed and managed the risks of infection. However, the registered manager told us 1 person had been diagnosed with an infectious heath condition. There was specific guidance in the person’s care plan around how staff needed to manage the risk of cross contamination and that, ‘Management will be doing daily observations to support and advise staff about following infection control protocols.’ However, there was no record that these checks were taking place or whether it was still required. This meant leaders were not assured staff were following the correct procedures. We also found that there was a communal stock of net knickers that people shared. This was not good infection control practice. We also observed a senior leader carrying a bag of soiled clothing without wearing gloves.

Other aspects in relation to the service infection control were managed well by the service. The home was clean and tidy, and we observed staff wearing ‘Personal, Protective, Equipment’ (PPE) where necessary. Staff told us they understood the importance of infection control. Comments included, “It keeps everyone safe. There is plenty of PPE, it’s everywhere” and “We have good housekeeping here; they keep on top of everything.”

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

At the previous assessment, leaders did not make sure that medicines and treatments were safe and met people’s needs. At this assessment, we continued to find concerns with medicines.

There were people that had been prescribed ‘as and when’ laxative medicine. However, where people had not opened their bowels for 3 days or more, as recorded in their bowel charts, they had not been offered the medicine to relieve their constipation. A senior member of staff told us, “If someone hasn’t [opened their bowels] for 1 day, then the following day, we need to offer medication. The seniors like to start with prune juice. [We] don’t let them [people] go for more than 3 days.” However, when we reviewed the care notes, people who had not opened their bowels for more than 1 day were not always being offered prune juice or the laxative. There was also no record in the ‘Multi-Disciplinary’ meetings records that external health professionals had recommended offering prune juice in the first instance. This placed people at risk of further harm from constipation as medicinal treatment was being delayed.

We found the temperature charts for the medicine rooms showed the room exceeded safe levels of 25 degrees. Although staff recorded that they would put the fan in the room if the temperature exceeded the safe level, they were not recording whether this was effective. Where people required prescribed creams to be applied, there remained gaps on their cream charts. Where handwritten medicine records were in place, staff were frequently not signing them, or counter signing them to ensure the accuracy of the medicine recorded.

However, since the last assessment, where people required a patch to be applied to their skin to aid with pain relief, staff were now recording where on the body it had been applied to reduce the risk of the skin irritation.