Hill Lodge

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Accident, incidents and safety concerns had been reported appropriately by staff and fully investigated by the managers. The records we reviewed demonstrated the learning outcomes from these investigations was shared with staff to ensure the risk of incidents reoccurring were reduced. Learning was shared across the providers different homes to ensure a good culture of continuous learning.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. Staff told us “Before a person moves in, we meet them, their families and people closest to them. We speak with any professionals involved in their care and complete assessments of their needs which forms the basis of their care plans. If the person wants to move in, we arrange day visits or take photos or videos to show them the environment, the room they would be moving into and discuss any adaptations that may need to be made.” Staff kept important information about people up to date and this was easily accessible to professionals who needed it. One professional told us, “When I first started visiting the home I was introduced slowly and with the consideration of each service user's needs. The staff worked with me to develop a trusted bond with each person, and we worked on the basis that if I too wasn’t a good match then we wouldn’t proceed as the service users' comfort was the main priority.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. The provider had a robust safeguarding system in place. Staff knew how to report concerns both internally and externally to the service. One staff member said, “Safeguarding means protecting individuals from harm, abuse, or neglect and ensuring their wellbeing and rights are respected at all times. Safeguarding involves being proactive and creating an environment where individuals feel safe and supported. If I suspected abuse, I would report it immediately. Following the whistleblowing policy if needed.” Safeguarding referrals had been made and actions taken to keep people safe. Deprivation of Liberty Safeguards (DoLS) were in place to legally authorise restrictions placed on people to keep them safe. Staff reviewed people’s DoLS to ensure all restrictions were noted and considered. One relative said, “On the whole we are very confident that [person] is safe, happy and well cared for.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Staff had assessed people for risks relating to their health, safety and welfare. Staff supported people to manage risks whilst maintaining their independence by promoting positive risk taking. For example, people were assessed for risks of falls, risk of choking and risk to their skin. When risk had been identified staff followed actions to keep people safe such as providing specialist equipment to protect people from skin damage. Risk assessments were regularly reviewed and updated when their care needs changed. Staff we spoke with understood the risks to people and the actions they needed to take to keep people safe.

The provider did not always do everything reasonably practicable to keep people safe from potential risks from their environment. The provider did not make sure that equipment, facilities and technology supported the delivery of safe care. The provider did not act in a timely manner to concerns raised about the environment. We identified concerns relating to fire doors not latching had been reported by staff to the provider on 18 February 2025 however, no action had been taken to rectify this. This meant people had been placed at risk of fire spreading through the home. We brought this to the attention of the provider who took immediate action to ensure the environment was safe before the end of our inspection.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. The provider followed safe recruitment practices and made sure staff training was up to date. The registered manager told us, “We have residents within the organisation that deliver training to staff because of their lived experiences they know what they want and how they wish to be treated.” One staff said, “I had two weeks induction. I have since gone on to have refresher training and new training that's been introduced. The training has always been excellent and always easy to access.” Bespoke training had been arranged for staff when it was needed to ensure people’s needs could be safely met. For example, staff completed additional training to use oxygen and suction machines to keep people safe. Staff told us they received regular supervisions and appraisals to support them to do their jobs well. One professional said, “From what I have seen the staff are trained appropriately and understand the needs of each individual in their care.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. We observed the service to be clean throughout. We reviewed records which demonstrated regular cleaning took place and received feedback from professionals and relatives who told us the home was always clean. One relative said, “The areas I visit are always clean and tidy.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Staff were aware of ‘STOMP’ (an initiative to reduce over-medication of people with learning disabilities and autism). Support plans had been created with people and those closest to them with techniques for staff to use at times of distress and this had led to successful reduction, and in some cases the stopping of the use of anti-psychotic medicines. This meant people no longer relied of the use of these medicines to improve their mood and behaviour as with the support of staff, they had learned skills to regulate their emotions and to express themselves in a constructive way. Staff asked people’s preferences for how they liked to take their medicines and followed this. When medicines were prescribed ‘when required’ there were personalised protocols to guide staff when these would be needed. Staff were trained and had competency checks to make sure they gave medicines safely. There were suitable arrangements for ordering, storing and disposal of medicines. There were regular medicines audits and areas for improvement were identified and addressed. Any medicines incidents were appropriately reported and investigated, so measures could be put in place to prevent a recurrence and learning could be shared.