Hillbeck Residential 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 Inadequate. This meant people were not safe and were at risk of avoidable harm. The service was in breach of legal regulation in relation to people being safeguarded from abuse, people’s safe care and treatment, the ways people’s medicines were managed safely and the lack of learning from incidents and accidents. The risks associated with people’s care were not always being managed in a safe way and there was not always sufficiently qualified and trained staff deployed to support people in a safe way. People’s medicines were not always being managed in a safe way. People were not protected from the risk of abuse. Incidents were not being analysed to reduce risk of reoccurrence.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The leaders did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate safety events appropriately. Lessons were not learnt to continually identify and embed good practice. There was a lack of robust management around accidents and incidents to minimise the risks to people. We saw from incident reports since August 2024 there had been 31 unwitnessed falls 17 of which were during the night shift. Although the records stated action was immediately taken by staff the leaders failed to ensure that incidents around falls had been analysed for themes and trends. There was no evidence they had considered whether the deployment of staff around the service needed to be reviewed to reduce further risks to people. This meant they missed opportunities to put in place necessary action to reduce further incidents and prevent avoidable harm or risk of harm to people.

The leaders did not make sure there was continuity of care, including when people moved between different services. Whilst the leadership team had undertaken assessments of people’s needs before they moved into the service, these were not always detailed and did not always provide guidance for staff on how to support people in a safe way. Where people had returned to the service from hospital, the care plan and risk assessments were not always updated with guidance for staff on how best to manage people’s changing health needs. For example, 1 person had returned to the service after having had aspirational pneumonia and had now been placed on a modified diet. There was a lack of detailed information for staff on what the person’s requirements around meals needed to be. Where people were due to move out of the service due to their changing needs, leaders had failed to ensure there was a safe transition. For example, 1 person was moving due to the service no longer being able to meet their needs. However, the person sustained a significant injury the day before they were due to move. The registered manager told us the person required a member of staff to be with them permanently but had not put this in place. They told us this was because the local authority would not fund this. However, the leaders had a duty of care to ensure the person’s safety before the moved out. The registered manager told us, “We were gutted [about the injury] because we kept (person) safe for so long.”

The leaders did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, avoidable harm and neglect. The leaders did not share concerns quickly and appropriately. Whilst people told us they felt with safe, we found people had not been protected from abuse and neglect. There had been allegations made against staff in relation to abuse and neglect dating back to February 2024. The leaders had not taken sufficient robust action or preventative measures to reduce any further risks to people. The leaders had not undertaken regular visits to the service out of hours to ensure people were being kept safe from harm. Whilst staff received safeguarding training, they failed to escalate concerns they had in a timely way.

The leaders did not work well with people to understand and manage risks. The risks associated with people’s care were not managed in a safe way placing people at risk of harm. Where risk assessments were in place, there was a lack of detailed guidance for staff. For example, the risk of choking, constipation, oral hygiene, dehydration and malnutrition. Where people had other health concerns, there was a lack of risk assessment or guidance in place. For example, 1 person told us they had a significant health condition. However, staff were not aware of this condition and there was very little reference to this in the person’s care plan around how this impacted the person. Where people required to have their fluid monitored, although there was target amounts set, these fluid amounts were frequently well below the targets. There was no evidence this had been addressed by the leadership team. Risk assessments were not always updated to reflect people’s current risks. For example, we saw from an incident form that a person had fallen. However, their falls risk assessment that had been reviewed since this incident, stated they had not had any falls and were determined as being at ‘low risk’ of falls. The Behaviour Support plans in place for people did not have sufficient guidance for staff on how to support people when they had incidents of distress. There was a lack of information on what may trigger people or how staff needed to respond when the person was directing their anxiety towards people and staff. This placed the person, staff and others at risk of harm.

The leaders had detected and controlled potential environmental risks in the service for the most part. However, we found people’s bathroom cabinets that held their prescribed creams and hygiene products, were unlocked, rusted casings were chipped, and paint was peeling off. We did find regular Health and Safety checks were undertaken by the maintenance team. All people had an up to date Personal Evacuation Plan in the event of an emergency such as a fire.

The leaders did not make sure there were enough qualified, skilled and experienced staff deployed around the service. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs. When we arrived at the service early morning, we found the majority of staff were congregated in the downstairs lounge. We observed there were people, at risk of falls, that were walking around the first floor. This left people at risk as there were no staff around to keep them safe. Where people were unable to use a call bell, according to their care plan, staff were required to check on them hourly at night. However, the care records showed this was not always taking place. For example, for 1 person, over 13 days, there were multiple occasions where the checks recorded were left for between 2 to 3.5 hours. This placed the person at risk as they had no way of alerting staff if they required support. We saw from incident records there had been 51 unwitnessed falls since January 2024, the majority of which had been at night. Yet the leadership team had not considered whether this pattern indicated a need to review the current staff deployment of staff at night. This lack of action placed people at further risk of harm. Staff had received training; however, this was not effective in ensuring safe practice. For example, we found staff lacked knowledge around how to safely support people when they were choking. We observed staff did not always have the skills to know how to respond to people living with dementia.

For the most part, the leaders had assessed and managed the risks of infection. However, we found, people’s toothbrushes had been left in bathroom cabinets that had spilled toiletry products inside of them. Staff received infection control training and staff we spoke with had a good understanding of how to prevent infections. The service was clean and tidy, and we saw staff adhering to good infection control.

The leaders did not make sure that medicines and treatments were safe and met people’s needs. Whilst there were some people that received their medicine as prescribed, there were elements to the management of medicines that were unsafe. Where people required prescribed creams to be applied, there were multiple gaps on the cream charts. Where people required a patch applied to their skin to aid with pain relief, staff were not always recording where on the body it had been applied. This meant there was a risk this could cause irritation to the person’s skin and staff may apply it in the same position. We saw examples of staff signing to say a person had received their medicines when they had not. Whilst this had been picked up on an audit, no action had been taken to address this with the member of staff who was still administering medicines on the day of the assessment. Where people required ‘as and when’ medicine to relieve their agitation, there was a lack of guidance for staff on when they needed to give. We saw 1 person had been given 11 doses of medicine for their distressed behaviour yet there was a lack of detail as to why this given other than, ‘for agitation.’ This meant, there was a risk the person was given sedation medicine when it may not have been needed.