Hillcroft 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 good. At this assessment the rating has changed to requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation 17 in relation to governance at the service.

This service scored 57 (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 business plan shared with us included a defined mission statement and set of objectives, demonstrating the provider had considered and established a strategic direction for the service. In addition, the provider had developed a service plan outlining their aims and objectives for the quality-of-care people receive. This incorporated key areas such as person centred care, dignity and respect, safe care and treatment, safeguarding people and duty of candour.

The provider had further developed business plans that included proposals for forthcoming renovation works. We saw evidence of ongoing work being completed in line with these proposals, this demonstrated a structured approach to organisational development.

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

Managers missed opportunities throughout to ensure care records were up to date and reflective of people’s needs. We found risks had not been identified such as unlocked sluice rooms and accessible medicines. We are aware the registered manager was working with the ICB for support, however, concerns flagged by the ICB were still occurring.

Staff treated people as individuals. People using the service and their relatives felt staff knew them well, including their preferences. A person told us, “Staff know about my history and like and dislikes.”

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

People and staff told us they felt comfortable raising concerns with the registered manager and the deputy manager. A person told us, “I know all the carers and management, and I know I could approach them if I had any concerns.” Staff we spoke with reported they felt able to approach the registered manager and deputy manager to share concerns if they had any. The registered manager explained they operate an open-door policy to encourage people to share their concerns or ideas.

While some staff told us they felt confident speaking with the provider, this was not the case for other staff we spoke with.

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.

Staff felt they were treated equally and without discrimination at work. Staff described the team and managers as supportive. Staff files were found to be up to date and fully completed, with regular supervisions taking place alongside routine team meetings.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance arrangements and systems were not robust to identify and address significant risks. We found there were not sufficient processes in place to monitor the safe storage and management of medicines. We found medicines belonging to one person located in another person’s room and found medicine was not securely locked away. We found poor PRN practices with protocols either missing or lacking sufficient detail to support safe and consistent administration. There were not sufficient processed in place to monitor the safe storage of COSHH items.

We found concerns relating to the management of the Deprivation of Liberty Safeguards (DoLS) process. A DoLS application had not been followed up in a timely manner to ensure the local authority had received it, nor was it chased for an outcome. The registered manager informed us the local authority had confirmed the application had not been received and this was sent retrospectively following our visit.

Care plans were not always fully completed, and we found instances where care delivery did not match information within care plans, for example a person with a catheter in place did not have this recorded in their care plan.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

We saw evidence to show the local church visited to deliver church services within the home for residents who wish to attend. We also saw different activities were planned to support residents to engage with each other, although we did not observe any activities whilst on site. There were no restrictions on visitor times, we saw relatives and friends visit people during both days on site.

We observed a community nurse deliver training to staff whilst we were on site, highlighting good collaboration and partnership.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

We identified areas where further improvement was needed to ensure learning opportunities were fully maximised. The registered manager had been engaging with the ICB to strengthen safe medicines management, yet we continued to find several concerns relating to the storage and administration of medicines. This indicated that lessons learned were not being embedded in a sustainable or consistent way across the service.

During our first visit, we discussed the importance of ensuring that COSHH products were securely stored. When we returned for our second day, these items were still accessible, demonstrating that immediate risks had not been adequately addressed and that required safety improvements had not been implemented in a timely manner. We have since received assurances from the provider items are now being stored safely.