Hilgay 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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last inspection we rated this key question good. At this assessment the rating has remained 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 71 (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 provider’s mission statement included treating people with dignity and respect, encouraging people to make their own choices, and supporting people to be involved in their communities. This mission had been achieved with staff supporting people to live the life they wanted and we observed this happening when we visited the home.

A staff member told us, “I think it’s very homely. We’re very close with the residents and we all get on well with them and their relatives. People feel very comfortable here. We have a tearoom so relatives can have a drink with their loved ones.” Staff completed equality and diversity training, and staff were diverse, coming from a variety of ethnic backgrounds.

The provider had inclusive leaders at all levels who understood the context in which they delivered care 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 registered manager said, “There is an open door policy and I also work on the floor, so I think that’s where I get the respect, and residents always want to chat.” The registered manager met with the provider regularly and maintained contact too through phone calls and emails. A staff member told us, “I think we have a very energetic manager. She gets you going, she’s a motivating manager and handles the residents well. Sometimes people want to talk to the manager rather than us.”

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

Staff told us they could voice any concerns they might have and any suggestions would be listened to. One staff member explained, “I do feel I can talk to [registered manager]. I am on sponsorship and she has made it quite smooth, I can go to her with any issues. We have staff meetings and are always putting our points across; we are listened to. Concerns about staffing levels have been listened to and we are getting an extra member of staff.”

The provider’s policies on whistleblowing and freedom to speak up guided staff on how to raise any concerns, at management level or anonymously.

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.

Some staff were employed through a sponsorship scheme. One staff member who was sponsored said, “I do feel valued and the residents make me feel that way too.” Another staff member said, “I’ve been here for a long time and I do feel valued. We are sometimes short staffed which can be quite hard, but this will improve when we have an extra member of staff.”

The provider took steps to ensure staff were treated with respect and any protected characteristics under the Equality Act 2010 were met. Staff meetings provided opportunities for staff to engage with the management team, and we reviewed minutes of meetings held in December 2024 and March 2025, which supported this.

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

A staff member said, “We have resident of the day and we make sure we complete observations like weight and their temperature. We make sure the person’s room is thoroughly cleaned and relatives will be contacted. Some will come to visit and we give them any updates.”

A robust system of audits had been established to monitor the service overall and to drive improvements. We reviewed a variety of audits including: care planning, dining room experience, health and safety, business continuity plan, and complaints. The registered manager engaged with people to ask for their feedback. They said, “I’m always open to suggestions and will try anything. We ask people about the food on offer and whether they are happy with the choices. One person fancied a Chinese meal and we arranged this for them. We have residents’ meetings and people give us ideas.”

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The home welcomed and were supported by a range of professionals, including health professionals and social workers. We asked several professionals for their feedback and received 2 responses. Feedback from healthcare professionals highlighted some concerns, such as care staff not always having detailed information about people’s care and support needs. Professionals also commented on the availability of staff when required, for example, when community nurses visited the home. The provider told us this situation would improve with the additional member of staff who has been recruited. In addition, a professional felt they were not always informed when people had been into hospital, but the home received good support from the local medical practice when people were discharged from hospital back to the home.

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.

Reflective learning enabled staff to look at any incidents and make changes to mitigate similar events from reoccurring. For example, changes had been made to how people were monitored if they sustained an injury and were on blood thinning medication.

Residents’ surveys provided feedback for the home on food and drink, staff, and activities on offer. People were informed about changes that were planned at the home including refurbishments and redecoration of the lounge.

Developmental opportunities for staff included studying for additional vocational qualifications if they wished.