Hillcroft 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 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.

The service was in breach of legal regulation 12 in relation to people’s safe care and treatment, and the way people’s medicines were managed.

This service scored 53 (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. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The provider had been working alongside the local authority to seek support in strengthening infection prevention control (IPC) practices and with the management of medicines. Action plans had been developed by quality monitoring officers as part of this support. However, there was limited evidence the provider’s own governance systems had identified these shortfalls or used learning from them to drive improvements. During both visits we continued to identify concerns relating to IPC and medicine administration. On the first day, we raised issues with the registered manager regarding sluice rooms being left unlocked and control of substances hazardous to health (COSHH) products remaining accessible to people in the building. These concerns had not been addressed when we returned on the second day, indicating a lack of timely action and oversight.

There had been no accidents, incidents or safeguarding incidents recorded over the previous 3 months. When we explored this with the Registered Manager, we were told accidents, incidents and safeguarding incidents were very rare, and none had occurred to report. Relevant policies were in place for safeguarding adults and for accidents and incidents, these set out the required procedures to follow should events occur. We noted our assessment feedback from our first day on site had been shared during a team meeting.

We saw a completed training matrix which showed effective oversight in ensuing staff training being kept up to date. We also observed staff completing training whilst we were onsite on our second day.

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 found systems were not effective to ensuring health specific care plans, such as those for catheter care were in place. We also found risk assessments had not always been fully completed or did not align with the actual delivery of care. For example, one person was recorded as needing medicine administered crushed or in liquid form, medicine administration records showed this was not happening. We found inconsistencies within care plans and sometimes there were no individual health care assessments in place. This meant staff could not always access guidance to support people safely. This increased the risk of people receiving unsafe care and support.

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 were no safeguarding referrals available to review, the registered manager told us there had been no safeguarding concerns to report within the previous 6 months. We saw evidence all staff had completed appropriate safeguarding training, and a robust safeguarding policy and procedure was in place. This provided clear guidance for staff on how to raise a safeguarding if safeguarding concerns were identified.

People told us they felt safe living at the service, and staff we spoke with were able to describe the actions they would take if they witnessed or suspected abuse. This demonstrated an understanding of their responsibilities in helping protect people from harm.

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.

We found risk assessments were not always fully completed and there were inconsistences between people’s care plans, their risk assessments, and the way their care was delivered. This included areas such as catheter care and the administration of medicine. Some care plans and risk assessments did not contain evidence people had been involved in developing their care plans or in discussions about how risks would be managed. This meant the service could not always demonstrate people’s preferences, views, and choices had been considered in planning their care.

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.

The service was undergoing renovation work during the assessment. During our visit we noted some window restrictors were not tamper‑proof and a wardrobe was not secured to the wall. These issues presented a potential risk to people, as unsecured furniture and inadequate window restrictors could result in injury. The window restrictors had been repaired by our second visit, the noted wardrobe was fixed, however, we found a further wardrobe which was not attached to the wall. On our second day we observed the fire escape was blocked throughout the day, which posed a potential safety risk. Demonstrating the provider’s internal systems for identifying and managing risks related to the environment were not effective. The provider has since given assurances fire exits are no longer obstructed.

The provider had developed an action plan identifying areas requiring improvement in relation to maintenance and décor. This showed the recognition of environmental issues, although broader governance arrangements were not effective in identifying and responding to risks across the service.

We identified concerns regarding the management of COSHH items. Sluice room doors were found to be unlocked on both days. These issues indicated that safe storage procedures were not consistently followed leaving people at risk of avoidable harm.

The provider shared long‑term renovation plans aimed at improving the environment, and we saw evidence of progress, including the refurbishment of the treatment room, the installation of new fire doors, and the creation of a new front office. A wide range of health and safety checks were in place, and assurances were given that these were being routinely completed. However, we identified a need for contingency arrangements to be implemented to ensure essential maintenance and safety oversight continued when work could not be completed within a timely manner. The provider has since given reassurances contingency plans are in place.

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 using the service generally reported timely support. One person told us, “They (staff) respond quickly if I use the call bell, on the occasion it rings longer than usual I hear the manager find out what people are doing.”

Training records showed staff had completed relevant training, and we observed staff taking part in a training session during our second day onsite. A staff member told us, “I have had excellent training.”

The provider had robust recruitment processes in place. Records showed appropriate background checks had been completed, helping to ensure people were supported by staff who had been recruited safely and were safe and suitable to work with vulnerable people.

A member of staff told us, “It can be very busy and sometimes we don’t get chance for a break. Sometimes I feel we need more staff.” The registered manager told us there were currently no vacancies within the service and agency staff were not used to deliver care. We reviewed rotas for the previous 3 months and found no gaps in staffing, and contingency plans were in place to cover annual leave and unplanned absences.

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.

We found several infection prevention and control (IPC) concerns, particularly relating to a shared bathroom, where there were significant levels of limescale around fixtures. We also noted bathroom fittings in people’s rooms on the ground floor were stained and pitted, the registered manager explained this damage had resulted from the use of unsuitable cleaning products. The condition of these surfaces could hinder effective infection control measures.

Staff had completed appropriate infection control training, and we observed them using personal protective equipment (PPE) correctly.

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

We found medicines were not being managed safely within the service. We found medicine belonging to one person located in another person’s room, indicating measures were not in place to maintain secure, individualised storage. We found a storage room containing medicines had been left unlocked, the medicine trolley was not secured to the wall when not in use, and whilst stored in a locked room the medicines fridge was left unlocked, increasing the risk of unauthorised access. In addition, we identified poor practice for as required medicines (PRN), with protocols either missing or lacking sufficient detail to support safe and consistent administration.