CQC report explained · a residential care home
What the CQC found at Hilgay Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, December 2021
Hilgay Care Home was rated Good overall; inspectors found kind, safe and personalised care, with some staffing pressure noted.
The inspection took place on 29 September 2021. One inspector spoke with five people, four staff, the registered manager and the provider. They reviewed care plans, medicine records, recruitment files, training information and quality records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that risks were managed, medicines were recorded safely, staffing levels were safe and people received appropriate food, drink and healthcare.
People described staff as kind and respectful. Care plans reflected people's choices, routines and communication needs. People were supported to stay independent, maintain relationships and take part in activities.
The previous overall rating was Requires Improvement, published in October 2020. Inspectors said improvements had been sustained. The Effective, Caring and Responsive ratings had improved from Requires Improvement at the January 2020 inspection.
Kind and respectful care
People described staff as kind, caring and pleasant. Inspectors observed positive relationships and respectful support.
“People told us they were happy with the service they were receiving and described staff as being kind and caring.” from the report
Personalised support
Care plans included people's routines, preferences, communication needs and own words. People were offered choices and supported to remain independent.
“Care plans were clear and well personalised to provide staff with the information they needed.” from the report
Safe medicines and risk management
Risks were assessed and reviewed, and medicines records were consistently completed. Staff understood people's individual medicines needs.
“Systems for managing medicines were safe and records were consistently completed.” from the report
Good food and healthcare support
People could choose meals and ask for alternatives. Staff monitored nutrition and hydration and involved healthcare professionals when needs changed.
“People were being supported to have enough to eat and drink.” from the report
Effective leadership
The home had systems to monitor quality and learn from incidents or audits. Inspectors found that improvements from earlier inspections had been maintained.
“The registered manager demonstrated they had clear oversight of the service.” from the report
Staffing pressure
needs fixingSome staff said that staffing issues during the COVID-19 pandemic had sometimes affected their ability to provide personalised care. New recruitment had started and new staff were appointed after the inspection.
“Some staff described the difficulties that they had experienced through the COVID-19 pandemic and the staffing issues that sometimes affected their ability to provide person centred care.” from the report
Medicines guidance oversight
needs fixingAn audit found that guidance had not been added when one person's medicine changed. The manager corrected this immediately.
“An audit of the administration of medicines identified a protocol, to provide guidance for staff, had not been put in place when a person's medicine had changed.” from the report
- 01What are the current staffing levels, and how do you cover shifts when staff are absent?
- 02How do you make sure staff receive and follow updated guidance when a person's medicine changes?
- 03What activities are currently available for people who do not enjoy group activities?
- 04How are people and their families involved in reviewing care plans and risk assessments?
- 05What improvements have been made since the September 2021 inspection?
This was a planned inspection covering all five key questions, including infection prevention and control under Safe. This explanation was written from the published report of 9 December 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, October 2020
Hilgay Care Home was rated Requires Improvement overall; inspectors found good safety and leadership, but some infection control work still needed completing.
This was a focused inspection on 17 September 2020. Inspectors checked whether improvements made after the previous inspection had continued. They spoke with people, relatives, staff and managers, and reviewed care records, medicines, recruitment files, training records and audits.
The home was rated Good for Safe and Good for Well-led. Inspectors found that risks were managed, medicines were given safely, staffing was sufficient, recruitment checks were completed and infection control procedures were mostly effective. They also found that management and auditing systems had improved.
The overall rating remained Requires Improvement because this inspection only looked at Safe and Well-led. Ratings for the other areas were carried over from the previous comprehensive inspection. Conditions placed on the provider's registration earlier in 2020 had been met and removed.
Risk management
People's risks were assessed and staff followed the guidance in care plans. Inspectors saw suitable support for a person at risk of choking.
“Risks to people were identified, assessed and managed safely.” from the report
Safe medicines practice
Medicines were stored, administered and recorded safely. Only trained staff administered medicines, and audits were used to correct any problems.
“Medicines were received, stored, administered and disposed of safely.” from the report
Improved management
The home had introduced effective audits and quality checks. The manager followed up actions and showed that reported improvements had been completed.
“At this inspection, these improvements continued to be implemented and were effective in developing the service provided at the home.” from the report
Positive relationships
People, relatives and staff described a more open and supportive home. Inspectors observed staff working together and treating people kindly.
“We observed staff supported each other and worked well together as a team.” from the report
Emergency planning
The home had personal evacuation plans and a grab box to help staff support people safely in an emergency.
“Personal Emergency Evacuation Plans (PEEPs) were in place for individuals.” from the report
Staff COVID-19 risk assessments
needs fixingIndividual COVID-19 risk assessments had not been completed for staff during the inspection. The manager said the process had started immediately afterwards.
“Individual COVID-19 risk assessments had not been completed for members of staff.” from the report
Overall rating remains Requires Improvement
needs fixingThe overall rating was not changed because this focused visit did not assess Effective, Caring or Responsive. Their previous ratings were carried forward.
“The overall rating for the service has remained as Requires Improvement.” from the report
- 01What are the current ratings and findings for Effective, Caring and Responsive, which were not assessed in this inspection?
- 02Have individual COVID-19 risk assessments for all staff now been completed, and when are they reviewed?
- 03How do you check that care plans and risk assessments are followed in daily care?
- 04How do you monitor staffing levels when new people are admitted?
- 05How will you keep relatives informed and support visits if COVID-19 restrictions change?
This was a focused inspection of Safe and Well-led, including infection control; Effective, Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 14 October 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Hilgay Care Home
9 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- December 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2020Requires improvementstayed Requires improvementSafe: GoodWell-led: Good
- March 2020Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2019Inadequatestayed InadequateSafe: InadequateWell-led: Inadequate
- July 2019Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementWell-led: Inadequate
- March 2019Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- August 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2015
Registered with the Care Quality Commission on 1 July 2015.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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