CQC report explained · a nursing home
What the CQC found at Hilltop Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, August 2022
Rated Requires Improvement; inspectors found kind and responsive care, but medicines, staff training, records and management needed urgent improvement.
Inspectors visited unannounced on 13 and 20 June 2022. They spoke with people, relatives, staff and a GP. They also observed care and checked care, medicine, staff and management records.
The main safety concern was medicines. Some medicines ran out or were missed. Records were incomplete, and some medicines were not stored safely. Records about modified diets did not always match professional advice, creating a risk for people who needed special food or drink textures.
There were enough staff to keep people safe, but staffing arrangements needed improvement. Some new staff had waited months for full training, and many staff had not received planned supervision. Leadership had changed frequently, and checks on medicines, staffing and records were not effective enough.
The home was rated Good for caring and responsive care. People were treated with kindness and dignity, and their needs, activities and communication were generally well supported. The overall Requires Improvement rating means the home was not consistently safe, effective or well managed, although the provider acted on some issues during and after the inspection.
Kind and dignified care
Relatives were mostly positive about staff. Inspectors found that people were treated with respect, had their privacy protected and were encouraged to remain independent.
“Staff promoted people's dignity and spoke about people with genuine respect.” from the report
Infection prevention
The home was clean and tidy, and inspectors were assured about its infection prevention arrangements, including protective equipment and outbreak management.
“The home was clean and tidy, and infection prevention control practices were well-embedded.” from the report
Personalised support
Care plans usually reflected people's needs, choices and preferences. The environment was adapted to help people living with dementia find their way around.
“Care plans identified people's support needs and provided guidance for staff on how to meet these needs.” from the report
Action after feedback
The provider responded quickly to several issues found during the inspection. This included changing staffing allocations, replacing the faulty medicine fridge and updating records.
“During and after the inspection the provider was responsive to all areas of feedback.” from the report
Medicines were not safe enough
seriousSome medicines ran out and were missed. Medicines were not always stored safely, and administration records were incomplete. This was a breach of Regulation 12.
“Medicines were not managed in a safe and proper way. This placed people at risk of harm.” from the report
Training and supervision gaps
seriousTwelve new starters had not completed the full training programme, and some had not received an induction. Half of care staff had not received supervision in 2022. This was a breach of Regulation 18.
“The support staff received was inconsistent.” from the report
Inaccurate diet records
needs fixingRecords about modified food and drink did not always match professional advice. Records about thickening drinks were also incomplete. This was a breach of Regulation 17.
“Inconsistencies with record keeping meant the service was not operating in the safest possible way.” from the report
Weak management checks
seriousThe home's systems did not reliably identify or address problems with medicines, staffing and records. Frequent changes in leadership had affected the service. This was a breach of Regulation 17.
“The provider's processes to monitor and improve the quality and safety of services were not always robust.” from the report
- 01What changes have been made to prevent medicines running out, being missed or being recorded incorrectly?
- 02How do you now check that medicines are stored at the correct temperature and that opened medicines are within date?
- 03Have all new staff completed their induction and required training, and how often do staff receive supervision?
- 04How do you make sure modified diets and thickened drinks match current professional advice?
- 05Who is currently leading the home, and how are you checking that the improvements requested by the CQC have been completed?
This was the home's first comprehensive inspection; a previous focused inspection in January 2021 covered Safe and Well-led, and this visit looked at all five key questions. This explanation was written from the published report of 4 August 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, February 2021
Inspected but not rated; inspectors found good safety and leadership, with care-plan detail needing improvement.
This was the home's first inspection. It was a focused inspection after concerns about medicines. Inspectors looked only at whether the home was safe and well-led. The inspection activity took place from 13 to 15 January 2021, with a visit on 15 January.
The home was rated Good for Safe and Good for Well-led. Inspectors found that medicines were generally managed safely, people felt safe, staff understood safeguarding, recruitment checks were completed, and infection control arrangements had been updated for COVID-19.
Inspectors found some care plans and risk assessments did not contain enough detail, particularly for people needing insulin or oxygen. Some electronic safety alerts had also not been set up. The home took immediate action, and inspectors found no evidence that anyone had been harmed.
The overall service was inspected but not rated because this inspection did not cover Effective, Caring or Responsive. The home was not placed in special measures.
Medicines generally safe
Medicines were stored securely, records were completed, and staff responsible for medicines had training and competency checks.
“Overall medicines were managed safely. People received their medicines as prescribed.” from the report
People felt safe
People and relatives told inspectors they felt safe. Staff understood how to recognise and report abuse.
“Relatives we spoke with felt their family member was safe living at the home.” from the report
Infection control
The home was clean, staff used protective equipment, and arrangements had been updated in response to COVID-19 guidance.
“Staff were provided with and used personal protective equipment such as gloves and aprons.” from the report
Active management checks
The home used audits and action plans to monitor medicines, care records and staff files, and to track improvements.
“Regular audits were carried out covering areas such as medication, care records and staff files.” from the report
Care plans lacked detail
needs fixingSome care plans for people needing insulin or oxygen were not detailed enough or were not followed by staff. Inspectors found no evidence of harm, and the provider took immediate action.
“for some people requiring support with insulin and oxygen the care plans were not sufficiently detailed or were not followed by staff.” from the report
Electronic safety alerts
needs fixingDuring the change from paper to electronic records, some safety alerts had not been set up. This included alerts about wounds and vulnerable skin.
“we found not all safety alert systems had been set up on the electronic system.” from the report
Mixed views about staffing
needs fixingSome staff said staffing levels were not enough to keep people safe, although others said there were enough staff. The home increased morning staffing after inspectors raised the concern.
“Some staff told us there were enough staff, whilst others said they felt there was not enough staff to keep people safe.” from the report
- 01How are care plans for people needing insulin or oxygen checked to make sure they contain enough detail and are followed?
- 02Have all electronic safety alerts, including alerts about wounds and vulnerable skin, now been set up and checked?
- 03How do you monitor staffing levels on each shift, particularly mornings, and what happens if staffing is not sufficient?
- 04How will you assess the areas not covered by this inspection, including Effective, Caring and Responsive care?
- 05What arrangements are currently available for relatives to visit or meet residents safely?
This was a focused inspection of Safe and Well-led after concerns about medicines; Effective, Caring and Responsive were not assessed and were not rated. This explanation was written from the published report of 10 February 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 Hilltop Lodge
Each visit the CQC has published, newest first, back to the day the home was registered.
- August 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2021Inspected but not ratedSafe: GoodWell-led: Good
- November 2019
Registered with the Care Quality Commission on 14 November 2019.
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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90 live-in carers within about an hour of Sheffield
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,270 a week. 76 can care for a couple. 11 years' experience on average.
“Carla has been a god send with the implementation of bringing mum back home from respite care.”
“Beatrice was a talent dementia carer whose professionalism and dedication allowed mums wishes to remain in her own her come true.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.