Hillbeck Residential Care 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 Inadequate. At this assessment the rating has remained Inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to the lack of robust governance at the service. There was a lack of robust oversight of the safety and quality of care.

This service scored 25 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

There was a closed culture at the service. A "closed culture" is a poor culture that can lead to harm, including human rights breaches and abuse. We found a poor culture continued at the service, which had not been adequately recognised or addressed by the provider.

Quality frameworks were not effective in identifying shortfalls in the care people received or gaps in people’s care records. At the previous assessment, we found the leadership team had not identified the institutionalised wording staff used in relation to the support of people including the term, ‘head count.’ Whilst this term was not used in care documents any longer, staff we spoke with still referred to this term when discussing with us about checking on people each hour. We also noted that leaders and all staff referred to people in care documents, incident forms and communication books as ‘room’ numbers which was undignified.

We found the registered manager did not demonstrate the required experience or capability to deliver person centred care or to ensure risks were well managed. They did not lead by example. We observed an incident where the registered manager was the only staff member present. A drink was grabbed forcefully by 1 person from another person which resulted in the drink being spilled on the floor. The registered manager did not raise this with staff and left the room with the person. The registered manager left the spilled drink on the floor without mentioning this to any staff. They also did not make a record of this incident in the person’s care notes.

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

The majority of the staff did not feel supported when it came to dealing with concerns. As in the last assessment, staff told us they had been raising with their seniors, their concerns about the conduct of staff they worked with. However, there was a lack of evidence action had always been taken swiftly to address this by the registered manager. We saw from supervisions that although the registered manager had referenced the concern the member of staff raised, there was a lack of recording by them of the specifics of the discussions.

We saw from a relative survey in March 2025 that it had been requested that a ‘relatives’ meeting would be appreciated. However, to date this has not been arranged. We saw from the August 2025 a planned meeting with relatives would be scheduled. However, the registered manager had emailed relatives to state this would not be a formal meeting as the Summer Fete would be taking place. Where relatives had given feedback for improvements on the survey, there was no action plan to state whether these improvements had been made.

We noted there had been incidents of distressed behaviours by people towards staff. There were no formal systems in place to have debriefs with staff to check to see how this had impacted them. One member of staff told us they felt completely unsupported by the registered manager. They told us they had been impacted by an incident occurring with a person’s distressed behaviour when they tried to protect a member of staff from being harmed by the person. The member of staff told us, “I stood in between (person) and the carer. I needed to stop it. Later I got called to (registered managers) office and he said, ‘What is it with you, why are you trying to get (person) removed from the home’.”

There had been improvements to ensure that night staff were not excluded from leadership presence. There were frequent visits at night by the leadership team and night meetings with staff were also taking place. There was also positive feedback from relatives about their interactions with the leadership team including, “I have had (emotional) meltdowns and there’s always someone to give you a cuddle”, “They’ve all be lovely, I can’t fault them, they’re approachable” and “I would see staff to raise anything, I’ve seen (registered manager), he’s always approachable.”

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

Leaders did not role model a shared vision, strategy or positive culture to staff. This had a major detrimental impact across all areas of people's lives. We found the leaders had not encouraged a positive culture where staff could feel they can speak up, that their voices would be heard, and their concerns listened to. As at the previous assessment, staff we spoke with did not always feel they could raise concerns with senior leaders including the registered manager. Comments included, “I won’t go to [registered manager] anymore if there are other managers in the room. (Registered Manager) is very kind and diplomatic but when other managers are around him, he just listens to them, not what I am saying”, “If you complain, because (staff member) is best friends with (a senior leader) nothing gets done” and “If you want to discuss anything like a concern, it’s a bit hit and miss whether anything will get done about it.” Leaders continued to fail to recognise they had developed a closed culture that did not promote or uphold people’s or staffs’ rights.

The provider did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The service failed to work towards an inclusive and fair culture by improving equality and equity for people who worked for them. We found at the assessment in February 2025, staff had not received appropriate training in this area and failed to demonstrate good values in relation to equality and diversity. Given this was a concern we found the majority of staff had still not received updated equality and diversity training. One member of staff said, “Sometimes, if I have been unhappy about something, I get told, ‘Why do you only come to me with issues?’ Not everyone is treated equally here when it comes to raising issues, so it’s not worth bothering with.” Another member of staff told us, “There are toxic (staff) here and everything is swept under the carpet. I have raised issues before particularly about (staff members), but they are ignored. Staff are allowed to get away with speaking like they do to staff.”

The provider did not have clear responsibilities, roles, systems of accountability or good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. They were unable to provide evidence of an effective system to assess monitor and improve the quality and safety of the services provided, and to ensure they had met the requirements of this regulation.

Whilst we saw that audits had increased since the last assessment, these were not being used effectively to sustain improvements. Leaders in the service were undertaking daily checks of continence and fluids however this was not robust as identified in this report. A member of the providers team was undertaking weekly medicines audits. However, the same issues were repeatedly being identified. Audits of a service's performance provides management with the information they need to decide whether the policies and procedures of a service are functioning as intended. This ensures standards of the service and the needs and expectations of people requiring care are being met. However, the audits were not always effective as shortfalls were not being robustly addressed, and improvements were not always being embedded. The leaders remained unable to provide evidence of an effective system to assess, monitor and improve the quality and safety of the service which continued to result in people having poor outcomes.

The leaders did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. We found at the previous assessment that leaders did not accurately share information and learning with partners or collaborate for improvement. The registered manager continued to have monthly ‘Multi-Disciplinary Meetings’ with health professionals. These were recorded in more detail than before. However, there still remained a lack of clear, up-to-date information to healthcare professionals to facilitate informed decision-making, streamline care processes, and promote a culture of safety and collaboration. For example, the registered manager told us they had consulted health professionals about 1 person’s increased agitation. According to the records, at the point of discussing the concerns with the GP, the person had only had 4 incidents over a 32 days. The registered manager told us there was no history of this distressed behaviour prior to this. However, the registered manager told us they had informed the GP that ‘multiple’ incidents of distressed behaviour had taken place. As a result of this information the GP had prescribed a sedative medicine for the person.

Whilst it was positive to see that health professionals were consulted, we found there was an over reliance by the registered manager on only taking decisive action in relation to people’s health care where a health care professional had instructed this. For example, the registered manager told us, regardless of how much weight a person had lost, they would only consider increasing the frequency of weighing people if a health care professional had advised them to do this.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcomes and quality of life for people. As found at the previous assessment, the registered manager told us they reviewed each person’s incidents forms and where necessary they would involve health professionals. However, there was no analysis of the overall incidents to look for trends, themes and triggers to try and reduce the risk of incidents which placed people at risk. We found there had been no analysis of the sudden rise in unwitnessed falls in July 2025 or of the high level of skin tears. There was also no analysis to review, understand and put robust strategies in place where people were having increased stressed behaviours.

Whilst the provider’s quality team were undertaking multiple audits, where shortfalls were being identified, this was not effective in improving on staff poor practice. For example, we saw the quality team were auditing medicines each week. However, repeated issues were being identified on each audit. The provider was not ensuring actions were being taken to make and sustain improvements.