The Care Quality Commission has today issued a statement after Keynsham residential care home Hillsborough House was rated as Inadequate and placed into special measures.
Inspectors who visited the Charlton Road home, run by the charity Freeways, discovered the home was dirty and smelly, with dried faeces found on a banister and in bedrooms.
Their visit in April was unannounced and partly prompted by concerns raised about safeguarding, the cleanliness at the home and the effectiveness of the registered manager.
Hillsborough House provides personal care to autistic people and people with a learning disability, those with mental health needs, physical disabilities, sensory impairment, and older people. There were 13 people living at the home at the time of the inspection.
The service’s overall rating has now 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 from 2018 remain.
The CQC has issued two warning notices to focus Hillsborough House’s attention on making rapid and widespread improvements in managing the safe care and treatment of the people living there, as well as the governance of the service.
The care watchdogs will closely monitor the service to keep people safe and if they don’t see sufficient improvement will consider what further action to take.
In a statement today, 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 smelled strongly of urine and their 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 residents 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 the people living there and staff and residents said staff were kind to them. Overall people were supported to have maximum control over their lives in the least restrictive way.
In a statement Freeways’ chef executive officer Claire Hayward said they were “deeply disappointed” that Hillsborough House had been rated as Inadequate.
“This is a wake-up call to all of us in the Freeways organisation and is also both exceptional and unexpected given Freeways’ long-established reputation as a centre of excellence in providing support and residential services to adults with learning disabilities.’
“While we take some encouragement that a more recent visit by a local authority commissioner recognised the significant remedial action that had already been undertaken, and also noted further scheduled improvements, we haven’t reached the standards of excellence we set ourselves.
“Freeways will be working tirelessly to make long-lasting and sustainable improvements to Hillsborough House and to raise it to the excellent standard of all Freeways facilities.”
Freeways operates and manages seven residential care homes, 10 supported living homes and community support across Bath & North East Somerset, South Gloucestershire and Bristol and North Somerset.
The charity said that this the first time in 35 years of providing support that any service has received an ‘Inadequate’ rating.
