CQC report explained · a residential care home
What the CQC found at Hillgrove Residential Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, April 2022
Hillgrove Residential Home was rated Requires Improvement; inspectors found safety and management weaknesses despite positive feedback about care and staffing.
This was a focused inspection on 25 and 27 January 2022. It was prompted by concerns about infection control and staffing, then widened to look at Safe and Well-led. An inspector and an Expert by Experience spoke with the manager and staff, contacted eight relatives, and checked care, medicine, recruitment and management records.
The home was not always safe. Inspectors found gaps in risk assessments, fire safety checks, medicine records, cleaning and COVID-19 testing records. They also found that some recruitment checks were incomplete.
The home was not always well-led. Quality checks were not regular or effective, and did not identify the problems found. There was also little evidence of regular feedback from people, relatives or staff.
The overall rating fell from Good at the previous inspection to Requires Improvement. The Safe rating was Requires Improvement. Well-led remained Requires Improvement. The other three key questions were not assessed in this focused inspection.
Staffing levels
Relatives and staff said there were usually enough staff to meet people's needs. Inspectors also saw staff spending time talking with people.
“Staff and people's relatives told us there were usually enough staff on duty to meet people's needs safely.” from the report
Positive care feedback
Relatives spoke positively about the care, respect and relationships between staff and the people living in the home.
“Feedback from relatives regarding the quality of care provided to people was positive.” from the report
Infection control equipment
Staff had suitable protective equipment and had received infection control training, although other infection control systems were not reliable.
“Staff had access to adequate supplies of PPE and had undertaken training in infection control and the proper use of PPE.” from the report
Response to incidents
Accidents and incidents were recorded and reviewed. The home sought advice from health professionals when needed.
“Records showed appropriate action was taken in response to any accidents and incidents and advice was sought from other health professionals when needed.” from the report
Risks and fire safety
seriousSome risks, including falls, COVID-19 and fire safety, were not fully assessed or reduced. Building safety checks and fire alarm checks were not completed consistently.
“Risks to people had not always been assessed or mitigated to maximise people's safety.” from the report
Medicines
seriousSome as-needed medicine instructions were missing, stock records were inaccurate, and competency checks were not available for all staff who administered medicines.
“Medicines were not always managed safely.” from the report
Cleaning and infection control
seriousCleaning schedules did not cover all areas, some areas were not adequately cleaned, and records did not show that all required COVID-19 tests were completed.
“Appropriate infection prevention and control measures were not all in place to prevent the spread of infection.” from the report
Quality monitoring
seriousAudits were not completed regularly and failed to identify important safety problems. The home also lacked regular feedback from people, relatives and staff.
“The systems in place to monitor the quality and safety of the service were not effective.” from the report
Recruitment records
needs fixingOne staff file lacked a reference from a previous employer, references were not always verified, and another file did not show the person's full employment history.
“However, not all other safe recruitment practices were always adhered to.” from the report
- 01What has been done to make sure falls, COVID-19 and fire risks are assessed and acted on for each person?
- 02How are as-needed medicines now explained, recorded and checked, and how is staff competency assessed?
- 03How often are all areas and equipment cleaned, including at weekends, and where can we see the completed records?
- 04Which building safety checks and fire drills are now completed, and how are missed checks followed up?
- 05How are relatives, people living in the home and staff now asked for feedback, and how is that feedback used?
This was a focused inspection of Safe and Well-led, including infection prevention and control; the other three key question ratings were not assessed in this inspection. This explanation was written from the published report of 14 April 2022 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, April 2021
Hillgrove Residential Home was inspected but not rated; inspectors found good infection control, with some improvement needed in the staff room.
This was an announced, targeted inspection on 16 March 2021. It looked at how the home was preventing and controlling COVID-19 infections.
Inspectors found good arrangements for safe admissions and visits. People and relatives were supported to understand isolation and infection control measures. PPE was available and used correctly, and testing was in place for staff, residents and visitors.
The home was mostly clean and had changed some areas to support social distancing. Staff had infection control training and the home had links with the local infection control team.
The service was inspected but not rated. This means the visit did not give an overall quality rating or a rated judgement for the other key questions.
Safe visits and admissions
The home had procedures for admitting people and allowing visits safely in line with national guidance.
“The service had procedures and protocols in place which ensured people were admitted into the service and people could visit the service safely in accordance with national guidance.” from the report
PPE and testing
PPE was widely available and used correctly. Testing was in place for staff, residents and visitors.
“Personal protective equipment (PPE) was widely available and used correctly and there was an extensive testing program in place for staff, people using the service and visitors.” from the report
Support during isolation
People and relatives were helped to understand isolation and infection control measures. The home also provided supervised visits and video and telephone calls to reduce loneliness.
“People and their relatives were supported to understand the isolation procedures and infection prevention and control measures.” from the report
Staff training and planning
Staff had infection prevention and control training, including refresher guidance. The home had plans for future disruption and infection outbreaks.
“Staff were trained in infection prevention and control (IPC) and had refresher training and guidance in COVID-19 guidelines.” from the report
Staff room needed improvement
needs fixingInspectors were only somewhat assured about the safety of the premises because the staff room area needed improvement in layout and hygiene practices.
“We were somewhat assured that the provider was promoting safety through the layout and hygiene practices of the premises, however the staff room area needed improvement as identified in the infection control audit.” from the report
- 01What changes have you made to the staff room since the inspection?
- 02How do you check that the staff room remains clean and supports infection prevention?
- 03How are visitors currently admitted and supported to visit safely?
- 04How often are staff, residents and visitors tested, and what happens after a positive result?
- 05How do you keep infection prevention and control training up to date for staff?
This was a targeted inspection of infection prevention and control under the Safe question; the service was inspected but not rated and the other key questions were not assessed. This explanation was written from the published report of 7 April 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.
Every inspection of Hillgrove Residential Home
4 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- April 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2021Inspected but not ratedSafe: Inspected but not rated
- February 2019Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- January 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 13 January 2011.
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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