Hillsborough House

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

Strong leadership was now visible at the service. People, relatives and partners spoke positively about the new registered manager. Where necessary, external health and social care professionals were now involved in people’s care planning. There was an open culture and team working was now evident. However, we found one continued breach of the legal regulations relating to good governance. Care planning information and governance systems for the oversight of medicines was not always effective. We have asked the provider for an action plan in response to the concerns found at this assessment.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service now had a shared vision, strategy and culture. Leaders said they had worked alongside people and staff to create a new shared vision and pathway to make improvements. Staff were now aware of the shared vision. For example, one staff member told us about the goals identified with people and staff in a home planning meeting.

The provider’s organisational values aligned to CQC’s Right Support, Right Care, Right Culture guidance, for example, putting people first, making sure people were the centre of their work and having staff with the right values to support people. The RM confirmed how they make sure they recruit staff who have the right values through the interview process.

The manager said they had support to undertake their role well from senior management through supervision, and regular meetings as well as peer support from other managers within the organisation. They explained how they attended Skills for Care registered manager meetings, where they shared ideas and found out more information to help them within their role. Leaders said the organisation provided opportunities for staff to train and progress their career. For example, a trainee management program was in place and this opportunity had been taken up by a staff member. One staff member said, “The manager is very passionate about her job, she wants people to go out, most people have been on holiday. People are treated with so much respect; I have never come across a manager like it.”

A new manager had been recruited since our last inspection and leaders now had the experience, capability, and oversight to ensure operational risks and team culture were managed well. Leaders were knowledgeable about where to access support to develop staff, for example, leaders regularly involved health professionals in providing specific guidance and training for the team.

Staff said they had opportunities to speak up if they had any concerns. Staff said they would speak with the manager about their concerns and expressed a confidence their concerns would be addressed. Leaders told us, “The organisation has had a real push around whistleblowing and speaking up to tell someone. And making sure senior managers are more visible in the service for people and staff to speak with if needed.”

The service now had policies and processes in place to give staff the freedom to speak up and to investigate concerns, these included regular staff supervisions and meetings.

Staff felt supported around their equality, diversity, and inclusion needs by the organisation. For example, staff spoke positively about how the organisation had supported them around their childcare and paternity leave requests. Another staff member said how they managed adjusted shifts to allow a staff member to take prayer breaks.

Systems and processes were in place to promote workplace equality, diversity and inclusion and ensure staff were aware of the policies around this. For example, staff received training on bullying and harassment and were made aware of updates to relevant policies through the service’s ‘read and sign’ system.

Leaders said they now had systems in place to check the quality and safety of the service, for example, a service action plan was developed following a full internal audit of the home completed by the organisation’s quality manager and this was being updated by the manager. Staff confirmed their awareness of their delegated responsibilities in the service.

Processes in place to check people's information and medication checks were not always effective. For example, information in some people’s hospital passports had not been updated to include recent SALT changes and a risk assessment had not been completed about a person’s anti-coagulant medicine. Medicines audits had also not always been effectively completed. The manager did immediately address issues we identified around people’s information and acted to make improvements around their medicines checks. However, other systems were in place to ensure continuity of service, for example the service winter plan was in place to keep people safe. The service was also in the process of transferring care planning information to an electronic format and there was a plan in place for how this should happen.

People told us they went out into their local area to do things they liked doing. One person said they had a bus pass and used the bus with staff support to go shopping or join a course.

Leaders said how they had worked in partnership with health professionals to improve outcomes for people; for example, the complex health team had delivered service specific training to help staff support people well around behaviours of distress and with their specific needs.

Partners spoke positively about their interactions with the service. One partner said, ‘The manager and team clearly want to work well in partnership to deliver well, in relation to the community learning disability team.’ Another partner told us, ‘The manager and the team have been quite proactive in sourcing support from our service for clients. If [RM] is unsure, she will ask our advice and opinion on matters regarding health needs. The manager and the team are always positive about training opportunities and are always happy to sign up to training that we provide to be able to support the clients better.’

Processes were in place for the service to work in partnership with others; for example, making referrals to health professionals and regularly seeking feedback from family members, friends and carers.

The manager said how they implemented improvements to a person’s environment to reduce the risk of incidents of distress for a person by providing them with a fridge in their room. Leaders said people were involved in the home’s improvement journey following the last inspection and developed the ‘service pathway.’ Leaders said, “The service pathway is a different way of working to involve the team and people to improve the service and ensure good outcomes for people.”

Processes were now in place to ensure the service learnt and improved. For example, Lessons learnt were discussed in team meetings and in the wider organisation to share learning. For example, the service had changed the way they use dishwasher tablets following learning shared from another service in the organisation.