Hillcrest Residential 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 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.

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. The provider did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learned to continually identify and embed good practice. For example, records used to monitor when people who experienced episodes of distress did not contain sufficient detail to enable staff to understand how best to support a person or identify further ways to improve support for them.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.We received mixed feedback regarding safe systems pathways and transitions. One A health professional told us, “We have worked with Hillcrest closely for over 12 months now and have found the home responsive to information provided. [Deputy manager] is clear wither their requests, if there are specific areas they have increased concerns around etc. and we are able to cover those in what we can provide to ensure the home can meet the patient’s needs safely. “However, people who used the service told us that they did not always feel involved in their care, with one person stating, “I don’t know what is happening, I don't know why I can't go home and have carers come and help me, I want my home."

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. People told us they felt safe when supported by the staff at Hillcrest, however one person’s needs had not been escalated quickly enough to the local authority safeguarding team, and lessons learnt following safeguarding concerns were not always evidenced.

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. People had care plans and risk assessments in place; however, we found that these did not always evidence clearly what support was required and at times stated contradictory information for example one person who displayed behaviours of anxiety had 3 sections within their care plan that all gave differing information for staff to follow. This led to staff not supporting the person consistently which had the potential to cause further distress. Other records such as weight and fluid monitoring and were also not fully completed.

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. Maintenance staff were on site 2 days a week, this meant any maintenance issues were not always addressed promptly when they arose on the maintenance persons days off. We also found that when they were on annual leave the weekly tasks were not undertaken. Objects, such as weighing scales, blocked the fire exits. This was raised immediately by the inspection team and action was taken. Maintenance issues were not always addressed in a timely manner. For example, there was a hole in the downstairs bathroom that required attention, this had been there for some time with no time frame for repair.

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. Staff recruitment processes were mostly in place with relevant checks of staff’s employment history, character, right to work, and checks with the disclosure and barring service (DBS). One member of staff did not have a DBS in place within their file, when brought to the deputy managers attention action was taken. Staff we spoke with were very committed about the work they did at Hillcrest, however felt a lack of staffing and resources impacted on the care they could give, A person that used the service told us “ I think its okay here, the staff look after me well, they don’t always have time to talk, but mostly it’s okay.” There were some missing items such as consistent supervision records for staff. Staff told us regular supervisions did not take place. One staff member said, “I can’t remember when I last had a supervision, it was a long time ago.”

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. When cleaning staff were on duty the home was clean throughout, however on the day of our first visit the no cleaning staff were on duty which led to the dining room not being cleaned following lunch. The home required redecoration and modernisation, this had been started, however further improvements were required. We found the home had appropriate PPE in place and staff said that this was always available.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning. Stock levels of medicines checked on the day of inspection were correct and stored within a locked drug trolley. ‘Date opened’ labels were added to medicine bottles and eye drops to ensure they were used within their expiry dates. People that had ‘as and when required’ (PRN) medicines prescribed had person-centred protocols in place to ensure staff would know when to give these appropriately. Most PRN doses were documented on the back of the medication administration record (MAR) to show why these were given, but there were some which were not documented. People who were prescribed creams had body maps in place to ensure staff knew where to apply these. However, creams were still being stored in residents’ personal bathrooms despite a recent audit stating these should be stored more securely. Good documentation was in place for medication that needed a certain time interval between doses, e.g. Paracetamol, to ensure that medicines were not given too close together. In the treatment room, temperature monitoring was not always documented as often as the home’s policy stated. However, the home was in the process of getting this room refurbished, so improvements were underway. This included getting a new medicine fridge which would show minimum and maximum temperatures. Since the Leeds Medicines Safety Team audit in April 2025, improvements had been made, and issues noted from the inspection were already on the home’s ongoing action plan.