Hillbeck Residential 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 Inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care. The service was in breach of legal regulation in relation to the lack of robust governance at the service and notifications not being sent to CQC as required. There was a lack of robust oversight of the safety and quality of care. Staff said they felt supported however they were not reporting concerns to the leadership team when needed.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Quality frameworks were not effective in identifying short falls in the care people received or gaps in people’s care records. The leadership team had not identified the institutionalised wording staff used in relation to the support of people including the term, ‘head count’ for checking people in their rooms, and ‘pad round’ when supporting people with continence care. We found leaders of the service did not demonstrate the required experience or capability to deliver person centred care or to ensure risks were well managed. They failed to recognise they had developed a culture that did not robustly promote or uphold people’s rights to be free from abuse and neglect. We found the leadership team was not always open and transparent with stakeholders and CQC in relation to all allegations of abuse. This meant professionals and people’s representatives were not always in receipt of information to make an accurate judgement about the quality and safety of the care provided, which put people at risk.

Although staff fed back positively about the leadership, we found the leaders had not considered the impact to staff when raising concerns about other staff they were working with including their seniors. Staff told us they had been consistently raising with their seniors, their concerns about the conduct of staff they worked with. However, there was a lack of evidence action had been taken swiftly to address this. We saw from staff meetings they were not always given an opportunity to feedback on any improvements that might need to be made. Whilst we saw the staff surveys, in the majority were very positive comments, there was also reference to a member of staff raising that they did not always feel listened to when they had concerns with ‘residents’ and staff. We saw from a meeting in October 2024 with senior carers, the registered manager referenced that staff had mentioned a ‘toxic’ working environment. The registered manager stated they were going in ensure that moving forward, once or twice a month they were going to work part of the night shift. However, this had not taken place.

Leaders did not role model a shared vision, strategy or positive culture to staff. This had a major detrimental impact across all areas of people's lives. We found the leaders had not encouraged a positive culture where people or staff could feel they can speak up, that their voices will be heard, and their concerns and suggestions listened to. Staff told us they did not always feel they could escalate their safeguarding concerns if they had already raised this with their seniors. This resulted in unsafe care, abuse and neglect to continue with people. The leaders failed to recognise they had developed a closed culture that did not promote or uphold people’s or staffs’ rights.

The service failed to work towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff had not received appropriate training in this area and failed to demonstrate good values in relation to equality and diversity. Staff fed back that at times there were staff that would treat them differently based on their cultural backgrounds. Although staff we spoke with told us they felt they were treated fairly by the leadership team. We found staffs human rights were not respected.

The leaders did not have clear responsibilities, roles, systems of accountability or good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. They were unable to provide evidence of an effective system to assess monitor and improve the quality and safety of the services provided, and to ensure they had met the requirements of this regulation. Although a number of audits were taking place, these were not robust and often had very little detail on any areas for development. The provider told us they also had concerns with audits not identifying areas for improvement. The providers electronic care system was able to produce reports to identify the safety and quality of care, however these were not being utilised. We were able to identify using this system, the lack of oral hygiene, personal care, the lack of fluid intake and staff not supporting people with appropriate foods. However, none of this had been identified by the leadership team. This meant they could not be assured that all areas of service delivery were monitored and that actions were taken to improve poor practice. The leadership team had failed to also notify CQC of safeguarding allegations and significant injuries which was a legal requirement. Leaders were unable to provide evidence of an effective system to assess, monitor and improve the quality and safety of the service which resulted in people having poor outcomes.

The leaders did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement. Whilst we saw ‘Multi Disciplinary Meetings’ were taking place with stakeholders, there was very little detail on what had been discussed in the meetings. Where advice had been provided by stakeholders, this was not always being followed.

The leaders did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcomes and quality of life for people. The leaders told us they reviewed each person’s incidents forms and where necessary they would involve health professionals. However, there was no analysis of the overall incidents to look for trends, themes and triggers to try and reduce the risk of incidents which placed people at risk. By systematically reviewing incidents services can implement changes that lead to continuous improvement. This might involve revising protocols, enhancing staff training that reduce the likelihood of future incidents. We found this was not taking place.