Highbury 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

During the last assessment the provider did not demonstrate effective governance, including quality assurance and health and safety auditing. This was a breach of regulation 17 (Good governance). During this assessment, we found the provider had acted on the areas of concern identified. However, additional governance concerns were found regarding care monitoring and auditing, making timely referrals to health professionals, and responding to environmental concerns. This meant the provider remained in breach of regulation 17 (Good governance). . The provider learnt lessons from the previous inspection and made improvements to the care and support provided to people. However, further improvements were needed to the overall governance. The manager was new to the service and in the process of registering with us. The manager responded to our feedback by introducing new systems to monitor care and maintenance requests. They arranged referrals with the appropriate health professionals and introduced new systems to monitor timely reassessments of people’s care needs with professionals. Staff told us they had confidence in the new manager's leadership and they felt able to raise concerns. The manager was aware of the duty of candour and shared their plans to continue to improve the care and support provided to people.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us where we would access the company values, they told us where these were located and pointed to them on the wall. Staff told us how they promoted people’s rights and encouraged people to achieve their goals.

The provider’s values and statement of purpose focused on valuing each person and ensuring people received person-centred care. However, further improvements were identified when monitoring the care and support provided to people, responding to environmental concerns and making timely referrals to health professionals.

The manager had recently joined the company and was in the process of registering with us. They understood the duty of candour. They told us how important it was to make apologies and to be open and honest. The manager was aware of the actions identified during the last inspection and had taken action to address many of the shortfalls. However, further improvements were needed to the overall governance of the care and support people received. Staff told us how the manager led by example. One staff member told us, “The manager is a good manager, they are really focused on making this a home. They are approachable and there when you need them. They lead by example and focus on the people living here.”

The manager was new to the role. They were proactive when responding to all concerns raised in this assessment. However, we raised concerns over the provider’s culture when responding to environmental concerns. The provider was slow to respond to environmental concerns despite these being raised promptly by the management team. The provider took action by introducing new systems to monitor maintenance and recruiting additional maintenance staff within the region.

Staff told us they now felt able to speak up and report concerns straight away. One staff member said, “The manager is doing a really good job, making positive changes. The manager is really focused. They are approachable and will listen to all of our concerns.”

The whistleblowing policy was accessible to staff, this was available electronically on a shared drive.

Staff told us the provider treated them fairly and respectfully. One staff member said, “There is diversity in the workforce, you can see by the culture. All staff are treated equally, they are quite good to be fair.” Staff told us they worked in an inclusive working environment. One staff member explained they experienced difficulties accessing the training online. They explained the provider assisted them, enabling space and time to complete their studies in the workplace.

The provider created an inclusive working environment. Interview records showed how the provider checked staff’s health prior to working to assess whether they needed any extra support. Anti-bullying and equality policies were in place to ensure staff were treated fairly and free from victimisation. Mindfulness resources were available to assist with staff wellbeing.

The manager had only been in post for less than a month, they were receiving support from the provider whilst becoming registered. Another manager from a different care home under the same provider was governing the home whilst the new manager was settling into the role. Whilst action had been taken to address many of the concerns raised in the previous inspection, further improvement was needed to the overall quality monitoring of the service. The new manager acted on all concerns raised in this inspection and put new systems in place to monitor the care provided to people. Staff told us they had confidence in the management team. One staff member told us, “The new manager is a really good manager. They have asked the staff team what we want to do to improve. They listen to our suggestions and take them onboard.”

During the last assessment the provider was in breach of regulation 17 (Good Governance). Incidents and accidents were not being reviewed, positive behaviour plans were out of date, health and safety checks were not available and there were numerous staffing concerns. The provider acted on all concerns raised in the previous assessment by introducing new systems and improving staffing levels. However, whilst improvements were made and quality audits were in place, these had not identified the areas of concern highlighted in this assessment. Internal and external audits were taking place; however, these had not addressed the gaps in health care tasks completed by staff. The audits had not identified the absence of oral care monitoring, the lack of information when recording health care appointments or the referrals which needed timely follow up. Internal and external audits had not addressed the slow response to maintenance tasks. Therefore, the provider remained in breach of regulation 17 (Good governance). The manager and provider acted on all of our feedback and introduced further monitoring and auditing systems. We will review the success of these new systems in our next assessment.

People told us staff were available to assist them and there were opportunities to share their views of the care and support they received. One person told us, “We have residents’ meetings. I can go and talk with my keyworker. They talk to me about how my care is going.” Relatives told us the provider had improved. Although one relative told us communication could be improved, they said, “There are regular reviews, but we would like more regular updates, such as what activities [my family member] has been on. We have met the new manager and they have told us about some of their plans, so communication may improve.”

The manager told us how they worked in partnership with other professionals. However, we raised concerns over the length of time it had taken to review people’s eating and drinking needs with health professionals. The manager explained they were new to the service and followed these concerns up during the assessment. Staff told us about their experiences working in partnership with other professionals. One staff member said, "We work alongside other professionals. Today [person's name] physiotherapist is coming. The district nurse visits here as well, so we work with them. When the physiotherapist last came they gave us guideline for the person's exercises and explained we should continue to do these with the person."

Visiting professionals told us the provider worked in partnership and shared information openly and promptly. One visiting professional told us, “Since the last assessment, I have noted areas of improvement throughout the service”. However they went on to explain there were areas to improve on, stating, “I noted gaps in weight and dietary requirements for individuals.”

The provider worked in partnership with several visiting health professionals, including advocates. However, improvements were needed to ensure people’s health needs were regularly monitored and reviewed in partnership with professionals.

Improvements had been made since the last inspection. However, further improvements were needed to the overall governance and responsiveness of the provider to environmental repairs. The new manager took action and told us about the monitoring systems they had established. These were put into place during this assessment. We will review the success of these systems in the next assessment. Staff told us they felt involved in the future plans and development of the home. One staff member told us how the manager had sought their opinions to develop and improve the service. Relatives told us the provider investigated their concerns. They said, “We would just raise it if we had any concerns. We would be confident it would be addressed. We once raised a concern. It was looked into and we were happy with the response.” People told us they would be consulted if their care plan changed. One person told us, “I think they would talk to me if they wanted to change my care plan.”

Action plans were in place in response to last assessment and the local authority quality visit feedback. However, these had not addressed all concerns found in this assessment. Further improvements were needed to ensure the provider was monitoring the service effectively. The provider shared their refurbishment and future plans showing how they intended to improve the care and support provided to people living in the home.