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CQC report explained · a residential care home, run by Freeways

Hillsborough House

59-61 Charlton Road, Keynsham, Bristol, BS31 2JQ

Goodpublished 29 January 2025, 19 months ago

Rated Good: inspectors found the service performing well and meeting their expectations.

The latest report, explained

What inspectors found, July 2023

Rated Inadequate; inspectors found improvements in fire safety, medicines and cleanliness, but the overall rating stayed inadequate.

This was an unannounced targeted inspection on 11 July 2023. One inspector checked whether earlier warning notices about safe care and treatment and good governance had been met. The inspector reviewed records and checks, looked around the whole home, and spoke with two people and six staff.

Inspectors found that improvements had been made. These included more frequent fire drills, better fire safety checks, referrals for dental and health support, building repairs, improved cleaning, safer medicines arrangements and more regular quality checks. The warning notices were found to have been met.

The overall rating stayed Inadequate. This was because a targeted inspection does not reassess every part of the service. Safe and Well-led were inspected but not rated, and the full service will be assessed at a later comprehensive inspection.

What inspectors praised

  • Fire safety work

    The home had acted on fire service recommendations, arranged an external fire risk assessment and increased fire drills to weekly.

    “At this inspection, we found improvements had been made. For example, the provider had implemented recommendations from the local fire service” from the report

  • Medicines checks

    Medicines were stored more safely and a second staff member checked medicines records on each shift. Errors or gaps were discussed and reviewed.

    “At this inspection we found the provider had worked with the local pharmacy and made changes, including implementing processes to identify potential recording errors quickly.” from the report

  • Cleaner premises

    Bathrooms, kitchen surfaces and flooring had been improved. Inspectors said the home looked visibly cleaner and did not smell unpleasant.

    “During this inspection, the premises looked visibly cleaner and was not malodourous.” from the report

  • More management oversight

    The provider had introduced an experienced management team, regular audits and action plans covering key areas of safety and quality.

    “An experienced management team had been introduced to the service and developed action plans, audits and checks that focused on continuing improvements.” from the report
What inspectors were concerned about

  • Overall rating remains Inadequate

    serious

    The home remained Inadequate after this inspection. The visit only checked specific parts of earlier concerns, so other areas still need a full assessment.

    “The overall rating for the service has not changed following this targeted inspection and remains inadequate.” from the report

  • Registered manager not in day-to-day charge

    needs fixing

    Although a manager was registered with CQC, that person was not running the home day to day when inspectors visited. Families should ask who currently has daily responsibility.

    “At the time of our inspection there was a manager registered with CQC, however they were not in day-to-day charge of the service.” from the report

  • Building work was still continuing

    needs fixing

    Repairs and improvements to the premises were not all finished at the time of inspection. An action plan was being used to monitor progress.

    “Improvements were ongoing at the time of this inspection and an action plan had been implemented to monitor progress.” from the report
Questions to ask them, based on this report
  1. 01Who is currently in day-to-day charge of the home, and how often is the registered manager present?
  2. 02Have all the fire safety recommendations and building works been completed, and what remains on the action plan?
  3. 03How are medicines administration records checked now, and how quickly are any errors or gaps followed up?
  4. 04How often are fire drills carried out, and how are people supported to understand what to do?
  5. 05What further work is planned before the next comprehensive inspection, given that the overall rating remains Inadequate?

This was a targeted inspection of specific concerns linked to Safe and Well-led; it did not assess the whole key questions, and the overall rating carried forward as Inadequate. This explanation was written from the published report of 21 July 2023 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.

An earlier report, explained

What inspectors found, June 2023

Rated Inadequate and placed in special measures; inspectors found serious safety, cleanliness, medicines and management problems.

This was an unannounced focused inspection on 25 April 2023. Inspectors looked mainly at Safe and Well-led. They visited the home, checked care, fire and medicines records, spoke with people and staff, observed care, and gathered views from relatives and professionals.

The home was not safe. Fire risks had not been dealt with, fire checks and drills were out of date, and some emergency evacuation plans were not properly reviewed. The home was visibly unclean, medicines were not always stored or given safely, and risks around one person's weight and another person's dental care were not managed well.

The home was also not well-led. Checks and audits had failed to find or correct the problems. The provider had not apologised to one person after an unintended outcome involving their dental care. Inspectors did see kind interactions, and staff knew people well.

The overall rating fell from Good at the previous inspection in 2019 to Inadequate. The home was placed in special measures. Some changes were made during or after the inspection, including cleaning, a fire risk review and changes to medicines storage, but CQC said it would continue to monitor the home.

What inspectors praised

  • Kind relationships

    Inspectors saw kind and caring interactions. People, relatives and a professional also described staff positively.

    “We observed kind and caring interactions between people and staff.” from the report

  • Staff knew people

    The report says staff knew people well and worked with professionals on some complex health needs.

    “We observed kind and caring interactions between staff and people; staff knew people well.” from the report

  • Recruitment checks

    The recruitment records examined included checks intended to help prevent unsuitable people being employed.

    “Recruitment checks we reviewed showed measures were in place to help prevent unsuitable applicants from being employed in the service.” from the report

  • Mental capacity safeguards

    Inspectors found the home was generally working within the Mental Capacity Act principles, with appropriate legal authorisations in place where needed.

    “We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place” from the report
What inspectors were concerned about

  • Fire safety

    serious

    Fire doors had known problems that had not been fixed. Fire risk assessments, drills and some emergency evacuation plans were not up to date.

    “The provider placed people at increased risk of harm in the event of a fire.” from the report

  • Cleanliness and infection control

    serious

    Inspectors found visible dirt, dried faeces, unpleasant smells and poor laundry arrangements. There was no cleaning schedule or record showing when areas had been cleaned.

    “The premises looked visibly unclean.” from the report

  • Medicines

    serious

    There were errors and missing checks in medicines records. One person's ear spray was given daily instead of weekly, and medicines were not always stored safely.

    “The provider failed to store and manage medicines safely. This placed people at risk of harm.” from the report

  • Individual health risks

    serious

    The home did not put enough support in place after one person lost significant weight. Another person had not been supported to attend dental appointments for over a year before needing emergency treatment.

    “The person had multiple teeth extracted during an emergency appointment.” from the report

  • Weak management checks

    serious

    Senior and service-level audits failed to identify serious problems with care, medicines, fire safety and cleanliness. Feedback from people was collected but not shown to be used for improvement.

    “Checks and audits undertaken at senior-leadership level had failed to identify the shortfalls we found at this inspection” from the report

  • Activities and smoking

    needs fixing

    People had mixed access to community activities and interests. Staff used the communal garden for smoking without asking people their views, and the activities board was blank during the inspection.

    “People had mixed experiences of being supported to access activities, hobbies, and interests.” from the report
Questions to ask them, based on this report
  1. 01What has been done to fix the fire doors, update the fire risk assessment, complete regular fire drills and review every person's emergency evacuation plan?
  2. 02How are you now checking that the home is clean, including bedrooms, toilets, shared areas and laundry arrangements?
  3. 03What medicines audits are now in place, and how are handwritten medicine records checked for accuracy?
  4. 04What changes have been made to monitor weight loss, arrange dental appointments and support people's other assessed health needs?
  5. 05How are people's feedback, complaints, incidents and safeguarding records now reviewed and used to prevent problems happening again?

This was a focused inspection of Safe and Well-led only; the report says ratings for the other questions were carried over from the previous inspection. This explanation was written from the published report of 16 June 2023 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.

The story over the years

Every inspection of Hillsborough House

7 rated inspections over 8 years: the service has slipped, from Requires improvement to Inadequate.

  1. July 2023Inadequatecurrent ratingstayed Inadequate
    Safe: InadequateEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Inadequate

    Read what inspectors found at Hillsborough House →

  2. June 2023Inadequatedown from Good

    Read what inspectors found at Hillsborough House →

  3. January 2019Goodup from Requires improvement
    Safe: GoodWell-led: Good

    Read this report on cqc.org.uk

  4. November 2017Requires improvementstayed Requires improvement
    Safe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement

    Read this report on cqc.org.uk

  5. August 2016Requires improvementstayed Requires improvement
    Safe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement

    Read this report on cqc.org.uk

  6. September 2015Requires improvementstayed Requires improvement
    Safe: Requires improvementResponsive: Requires improvement

    Read this report on cqc.org.uk

  7. April 2015Requires improvement
    Safe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement

    Read this report on cqc.org.uk

  8. September 2014

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  9. August 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  10. February 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  11. November 2011

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  12. January 2011

    Registered with the Care Quality Commission on 5 January 2011.

Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.

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