The Care Quality Commission (CQC) has rated Hillsborough House, a residential care home run by Freeways in Keynsham, Bristol as inadequate and placed it into special measures following an inspection in April.
Hillsborough House is a residential care home providing personal care to autistic people and people with a learning disability, people with mental health needs, physical disabilities, sensory impairment and older people.
This unannounced focused inspection was prompted by safeguarding concerns, the cleanliness of the service and the effectiveness of the registered manager and safeguarding concerns.
Following this inspection the service’s overall rating has dropped from good to inadequate, as has the rating for how safe, and well-led the service is. This inspection did not look at how effective, caring and responsive the service is, so the previous ratings remain.
The service has now been placed in special measures and the CQC has issued two warning notices to focus Hillsborough House’s attention on making rapid and widespread improvements in how they are managing the safe care and treatment of the people living there, as well as the governance of the service.
CQC will closely monitor the service during this time to keep people safe. If CQC don’t see sufficient improvement we will consider what further action to take.
Rebecca Bauers, CQC’s director for people with a learning disability and autistic people, said:
“Our experience tells us that when a service isn’t well-led, it’s less likely they’re able to meet people’s needs in the other areas we inspect, which is what we found at Hillsborough House. Poor leadership had undermined the standards of care people were receiving, and they weren’t safe because they were at risk of avoidable harm.
"We saw basic issues like people’s safety in the event of a fire not being considered because the provider didn’t carry out things like required fire drills every three months, despite being told previously we had concerns. We referred the provider to the fire service and local authority around this.
“We saw that despite the best efforts of staff, who were kind and caring, both they and people who called Hillsborough House home, were being let down by poor leadership, which impacted on every area of their daily life.
“The culture at the service wasn’t dignified, with people being expected to live in a dirty, unpleasant smelling environment, that posed an infection risk. We found dried faeces on a banister, stained surfaces throughout and unknown residues and debris on walls and floors. People’s bedrooms were also dirty and smelled of bodily fluids. Staff told us they didn’t have time to clean.
“People's oral hygiene wasn’t being supported and as a result and in one case, urgent emergency treatment was required. This was unacceptable.
“In response to our feedback during the inspection, the provider made some changes, including arranging for a deep-clean, for a fire risk assessment to be undertaken with an external contractor and amendments to how medicines were stored, but they have much more that needs to be addressed.
“Leaders know what needs to be improved, and if we do not see rapid and widespread improvements, we won’t hesitate to take further action to keep people safe, which may include preventing them from operating.”
Inspectors found:
- One person at risk of weight loss had lost a significant amount of weight over two months because no risk assessment or review of their care needs had taken place with no plan in place about how they were being supported to maintain or put on weight
- There were no medicine audits in place and medicines were not stored or managed safely. For example one person's ear spray, which should have been sprayed in each ear once a week, was administered daily over 27 days
- One person's bedroom was malodorous and smelled strongly of urine, the same person's toilet was stained black. Another bedroom had dried faeces on the floor and chest of drawers, as well as soil and discarded food wrappers
- Laundry was stored near to a communal toilet and in baskets in the communal dining area which increased the risk of cross-contamination and infection
- The floor and a chest of drawers in one bedroom was covered in dried soil and discarded food wrappers
- People had mixed experiences of being supported to access activities, hobbies, and interests. Records showed some people hadn’t been supported to access the community for prolonged periods of time. People told inspectors that they would like to consistently do more fun activities and they don’t get out very often.
However,
- Inspectors saw kind and caring interactions between people and staff and people said staff were kind to them
- Overall people were supported to have maximum control over their lives in the least restrictive way.