Hillgrove Residential Home

Updated 14 April 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This included checking the provider was meeting COVID-19 vaccination requirements. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was undertaken by an inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Hillgrove Residential Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

On the first day we gave four hours' notice of the targeted inspection. The second day of the inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service.

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.

We used all this information to plan our inspection.

During the inspection

During the inspection we spoke with the manager and three members of the staff team. We contacted the relatives of eight people who lived in the home over the telephone, to gain their feedback and experiences.

We reviewed a range of records. This included three people’s care records and multiple medication records. We looked at two staff files in relation to safe recruitment. A variety of records relating to the management of the service, including audits were also reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found during the visit and that sent electronically following the visit.

Updated 14 April 2022

About the service

Hillgrove Residential Home is a residential care home owned and managed by the provider Mayflower Care Homes Limited. It is registered to provide accommodation and personal care to up to 23 people. At the time of this inspection there were 19 people living at the home.

People’s experience of using this service and what we found

The systems in place to monitor the quality and safety of the service were not effective. Audits were not in place for all aspects of the service, they were not completed regularly and did not identify the risks that we highlighted during the inspection. Systems were not in place to gather regular feedback from staff, people or their relatives, regarding the service, to enable changes and improvements to be made as necessary.

Although risk assessments and care plans were in place, risks to people had not always been assessed or mitigated to maximise people’s safety, such as those relating to COVID-19, falls and fire safety.

Medicines were not always managed safely. Protocols were not in place for all medicines prescribed 'as and when required' and stock balance checks were not all accurate. Staff had undertaken medicine training, but records of competency assessments were not available for all staff who administered medicines.

Appropriate infection prevention and control measures were not all in place to prevent the spread of infection. Not all areas of the home had been thoroughly cleaned and although cleaning schedules were in place, they did not cover all areas of the home. Staff told us they completed regular tests for COVID-19, however records did not support this. Staff had undertaken infection control training and had access to appropriate PPE.

Staff recruitment records showed that all staff had a disclosure barring check prior to commencing in post, however, not all other safe recruitment practices were adhered to. We made a recommendation about this in the main body of the report.

People’s relatives told us they felt their family members were safe at Hillgrove and feedback regarding care provided was positive. There were enough staff to meet people’s needs in a timely way and staff were aware of how to raise any safeguarding concerns they had. Relatives told us they were kept informed of any changes regarding their family member and had been able to have contact with them during the COVID-19 pandemic.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk.

Rating at last inspection

The last rating for this service was good (published 20 February 2019).

At our last inspection we recommended that the provider ensured the rating of the service was displayed on their website as required. At this inspection, we found that this had been actioned.

Why we inspected

The inspection was prompted in part due to concerns received about infection prevention and control and staffing issues. A decision was made for us to inspect and examine those risks.

We inspected and found there was a concern with the infection prevention and control measures in place, so we widened the scope of the inspection to become a focused inspection which included the key questions of safe and well-led.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to infection prevention and control, management of medicines, risk management and the governance of the service at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.