Hilgay 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 good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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.

People felt staff were open and honest with them if things went wrong. One person said, “I wouldn’t want to be anywhere else. I think the atmosphere is nice, always jolly. If you want help, it’s always there.” Staff knew how to report any incidents with the knowledge these would be used to drive improvements. One staff member explained, “I would go to my team leader and report to him or to the manager.”

The registered manager provided an example of an incident that had occurred last year when a relative said they felt communication could be improved. As a result, the registered manager kept relatives informed by a monthly update, about their loved ones’ care and support, and what they had been doing.

Accidents and incidents were reported, investigated, and used for reflective practice. Duty of candour was understood and adhered to.

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.

Staff worked as a team to ensure consistency of care. A staff member told us, “Person-centred care is for the individual specifically and what their needs are; it’s not standard care. When I’m team leading, if a person needs to go into hospital, I make sure they have the clothes they like to wear, their medication, and medication charts printed out for them.”

Where people’s needs required specialist input, a referral would be made to the relevant team. For example, to a speech and language therapist when a person had difficulty with swallowing, so a pureed diet was recommended. Pre-admission assessments were completed and ensured people’s needs could be met and appropriate support provided, with staff receiving additional training if required. For example, staff used signing to communicate with a person as this was their preferred method of conversation.

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 protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

There had been concerns raised by a relative over several months. These had been handled appropriately by the registered manager and notified to the local authority as needed. People told us they felt safe at the home. One person told us they might feel unsafe if there was a fire, “But I haven’t thought about it and we do have fire drills.”

Staff completed safeguarding training which was refreshed annually. A staff member said, “It’s about protecting the residents. If I have any concerns I would go to [registered manager] and vice versa, with the residents, if they had any concerns, I would forward them on. I would try and help the resident anyway I can.”

Notices providing information on how to report a safeguarding concern were on display, and staff had access to the provider’s safeguarding policy. Any incidents of abuse or alleged abuse were reported to the local safeguarding authority and to CQC in line with regulatory requirements.

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.

One person explained their difficulty sometimes in being able to swallow their medicine. This had been discussed with the registered manager and an option of taking the medicine with yogurt, with GP consent, had been considered. Staff supported people to be safe, for example, by ensuring fire doors were not obstructed, hazardous chemicals were kept securely, and sensor mats monitored people’s movements. Continuous monitoring by staff when providing personal care, ensured people’s risk of skin damage was mitigated.

Risk assessments about people provided detailed information for staff to follow. For example, people prescribed blood thinners had anti-coagulant care plans and mobility risk assessments to mitigate risks relating to internal bleeding or hypovolemic shock.

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 home provided a safe environment for people. A staff member said, “We had a fire practice recently. We had to make sure the fire drill was kept to, nothing obstructing the doors, knowing the different areas of the home, where the fire extinguishers are and what they are used for. Knowing the drill and assembly is outside by the entrance. We have a fire mat to slide people down the stairs and we are trained for that.”

The home was under refurbishment at the time of the assessment and this was managed safely. The lounge was being cleared for redecoration and people were using a smaller lounge instead. Signage around the home helped people to navigate, and easier access was provided with a lift, handrails and ramps. Audits showed fire risks were managed well, and water testing included Legionella management and temperature monitoring. Equipment used for moving and handling was checked regularly for safety and repair.

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.

People had mixed views about the number of staff available to provide care. One person said, “They need more staff, because people’s needs are greater now and staff are rushed off their feet.” Another person commented, “Staff are always laughing and joking, I get on with everyone.” Staff told us things had improved and a new ‘multi-tasker’ member of staff was due to start, with the responsibility to step in where required. For example, this new member of staff could assist with breakfast, and help with the laundry, thus freeing up care staff.

Staff were recruited safely with all appropriate checks completed to ensure they were suitable and of good character to provide personal care. Staff completed a range of training as part of their induction. Staffing levels were sufficient and were reflected in the staffing rotas reviewed as part of this assessment. In addition, the provider was in the process of recruiting to a deputy manager post.

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 home was clean and well maintained. Staff wore personal protective equipment (PPE) when providing care to people and when giving people their lunchtime meal. A staff member told us, “If someone has an infection, we have a PPE station outside their door. At night-time, we wipe all the chairs down, clean the kitchen, we know where the cleaning products are and wear gloves.”

We received copies of the provider’s infection prevention and control policy, kitchen audit, outbreak management and isolation nursing policy and environmental audits, which provided information to staff. These audits identified any actions needed to drive improvement.

Some aspects of medicines were not managed safely.

We reviewed medicines that required special security measure.We found some medicines still being stored for 3 people who had passed away, including 1 person who had died in January 2025. We discussed this issue with the registered manager who arranged for the medicines to be collected by the pharmacy the next day. Stocks of 1 medicine were inaccurately recorded and this was promptly rectified when we raised the concern with staff. Medicines audits had been completed but had not identified the issues noted here.

We observed medicines being given to people by a staff member at lunchtime. This was done sensitively and in a caring way. Medicines were stored in a trolley which was securely locked when left unattended. The staff member wore disposable gloves when giving people their medicines. Medicines were all within date; only staff trained to administer medicines did so. A staff member told us, “I did medicines training on the website as well as in-house training. We also did training with another team leader who showed us what to do, then we have a questionnaire that we need to answer and be signed off. Medicines competency will be signed by [registered manager] and 2 other team leaders.”