Highbury Rise

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 requires improvement. At this inspection the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 47 (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 did not always have a proactive and positive culture of safety based on openness and honesty. The management team did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Some learning was taken and shared with the staff team from events, incidents and inspections. This was discussed at handovers, team meetings and as part of day-to-day discussions.

However, there was a lack of progress from our last assessment as some shortfalls previously identified remained an issue. For example, in relation to medicines management and recruitment records. In addition, a recent hospital admission for a health condition had not generated an action for this health condition training to be included as it was listed as ‘N/A’ on the training matrix.

We also found notifications had not been sent to the Care Quality Commission when notifiable events had happened.

People and relatives told us the management and staff team asked for their views and took any action that may be needed. They said feedback and updates were shared with them.

Staff told us learning from events, complaints and updates was shared through meetings and handovers. A staff member said, “I am kept up to date with changes through training, meetings, and communication from management.”

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.

People and relatives felt the move into the service had been good. They told us the team had ensured the move was as easy as possible and they felt very supported.

There was positive feedback from visiting professionals.

People received a preadmission assessment prior to moving into the service. Records were held on file and information was to be shared with healthcare professionals as needed. This was used to help inform the care planning process. A staff member said, “I receive sufficient information when a new person joins the service, including care plans and risk assessments.”

The provider did not always concentrate on improving people’s lives or protecting their right to live in safety, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Safeguarding concerns were not always processed, reported and recorded appropriately. Where people had experienced unexplained injuries, such as for 1 person a fracture, this was not reported or investigated. The service supported people with complex needs and at times were verbally abusive to other people living in the home and staff, these events were not reported either.

People told us they felt safe living at the service. Relatives felt their family members were safe. However, some people said they found an issue with another person living at the home difficult. Staff were doing their best to manage this complex situation; however, it had an impact on people’s daily life.

Staff told us they knew how to recognise, and respond to, abuse. A staff member said, “If concerned about someone’s safety, I follow safeguarding procedures and report immediately to the senior or manager.” Staff told us they would speak up when needed.

Staff were observed being kind in their approach and gentle when supporting people. People were relaxed and comfortable with staff.

Staff received training in relation to safeguarding people from the risk of abuse and information was displayed around the home.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People had individual risk assessments, and these gave guidance to help ensure staff supported people safely and were regularly reviewed. However, these were not always followed in relation to pressure care management. We noted people did not always receive support to reposition at their required frequency. We reviewed records of 4 people who required repositioning to reduce the risk of developing a pressure ulcer. All 4 had gaps in their required position changes or were repositioned on to the same body part which does not relieve pressure. For example, a person whose care plan stated they needed to change position 2 hourly, remained in the same position for up to 10 hours during the day.

People and their relatives told us they felt staff supported them safely.

Staff told us about risks to people and the action they took to help reduce those risks. For example, in relation to falls, dietary needs and supporting people when they felt anxious or distressed.

We saw staff supporting people to move around safely, respond to calls for assistance and carry out regular checks. Staff ensured people were sat up when eating and drinking.

The provider detected and controlled potential risks in the care environment in most instances. They made sure equipment, facilities and technology supported the delivery of safe care.

People had access to call bells and for those who were at risk of falls had sensor mats to alert staff to their need of assistance.

Staff were aware of hazards and how to reduce these. Staff had attended fire drills and people had individual evacuation plans. There was firefighting and evacuation equipment in place. Tests were being carried out on water systems as required. Some remedial work was needed and due to be added to the action plan when the report was received.

The building had various sitting areas and people could choose where they wanted to sit and spend their day. People were using the 3 communal areas depending on their preference of a busier space, TV room or quiet lounge. We observed people moving around the home and staff helping to orientate them as needed.

There were regular checks carried out on the environment and equipment to help ensure the appropriate servicing was carried out and everything was in working order. There had been work completed on fire doors and a new cooker purchased. However, the woodwork was in need of redecoration from where it had been damaged by equipment moving around or worn over the years. There was also a bathroom which needed a tile repair. The management team told us a refurbishment plan was to start in January 2026.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

We reviewed the training provided and saw this covered all mandatory subjects, however, some was due for renewal or needed to be completed. This also included for the registered manager.

Recruitment followed a process carrying out checks to help ensure staff were suitable to work in a care setting. These checks included criminal record checks, verifying applicants’ identities and written references. However, this did not always ensure full employment history was documented as part of the application process. This was a repeated shortfall from our previous inspection.

There was a checklist to be completed to ensure all required information was in place and verified. However, this wasn’t consistently used and meant gaps in employment were not identified and a record of people’s identification documents were saved as part of the file.

Following our feedback, the provider advised they had the required information and this was now in staff member’s files. However, the oversight of this had not been robust and showed governance systems were not always used effectively.

People said there were enough staff to meet their needs. A person said, “They are always around.” Another person told us the staff arrived promptly when they pressed their bell. Relatives said they felt there were enough staff, and staff were trained for their role. A relative said, “To my knowledge staff training is sufficient to enable them to their jobs.”

Staff said there were enough of them to meet people’s needs in a person centred and timely way. A staff member said, “Staffing levels are generally well-managed to meet people’s needs.”

Staff felt they received enough training and support to carry out their role. A staff member said, “I feel I have received adequate training and support to perform my role confidently. My competencies have been checked, and I have regular supervision with my line manager.”

Staff were visible and prompt when people requested support. Staff were taking their time when supporting people and carrying out regular checks.

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 if and when needed.

People’s bedrooms and most communal areas were kept clean. Some areas, such as woodwork, needed a deeper clean.

Staff knew how to practice good infection prevention and control (IPC). A staff member said, “I have had infection control training, which informs daily practices such as PPE use and hand hygiene.”

Staff were practicing IPC in their day-to-day roles. We observed correct handwashing and use of personal protective equipment (PPE).

There were IPC audits and checks in place.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

At our last assessment we found there were shortfalls in relation to management of medicines. At this assessment we found while the service had moved to electronic medicine records to help address these issues, the same shortfalls remained.

There was an electronic medication record system, this provided alerts for any due or missed medicines to help ensure the safe management of medicines. However, we found quantities were not always input into the system accurately which meant the quantity of medicines in the building was not always correct. We found 2 medicines where this had been an issue. The deputy manager told us they were working through the system to ensure inputted records were accurate. Further work was needed to ensure this was not an issue in the future.

Body maps completed to support the administration of pain relief patches for 1 person were not completed accurately. While we saw the medication administration record documented when this had been given, the map used to show where it was placed and when it was removed had gaps of administration.

People received their medicines in accordance with their needs and as the prescriber intended. Staff were carrying out administration tasks safely and in a timely manner.

Staff responsible for managing medicines were aware of safe practice.

We reviewed a sample of audits and found these were checking the appropriate elements, such as quantities, entries and storage of medicines, however they did not identify the shortfalls we found as part of this assessment.