Highbury Rise

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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service which included not sending statutory notifications and oversight of recruitment records.

This service scored 62 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff were positive about how the team engaged in helping people live their best lives. A staff member said, “Care is person-centred and families are involved where appropriate.”

Feedback from people and their relatives was obtained through meetings and surveys. Meetings were held with staff to share information.

The provider had introduced a themed project from staff, visitors and residents across home to increase inclusion. Carnival celebrations had been held and there were environmental sustainability project across the provider’s homes. An autumnal project had ended November 2025 and the Christmas of Hope project 2025 was in process at the time of our visit. The provider gave prizes and awards for residents and care homes on innovative ideas.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff were positive about the culture and approach in the home. A staff member said, “I would recommend the service both as a workplace and for people receiving care.”

The provider had implemented new processes to improve people’s lives and experiences. This included actions being taken following our feedback to address shortfalls identified during this assessment to reduce the risk of impact on people. For example, additional training modules and audits.

The provider fostered a culture where people felt they could speak up and their voice would be heard.

Staff were positive about how the management team engaged with and involved them. A staff member said, “Staff are asked for feedback, and I feel able to speak openly.” Staff told us the management team were visible and approachable.

There were resident, relative and staff meetings. A survey for people, relatives, and staff had been carried out by an external agency. An action plan was suggested by the agency. Actions were recorded in a ‘You said, We did’ response. This included requests for additional activities, feedback on environment and menu suggestions.

Relatives had contact with staff and managers, and during assessment, care planning and events in the home. This enabled effective communication and sharing of feedback.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff felt supported and respected by the management team. A staff member said, “I believe staff and residents are treated respectfully.”

The provider had an equal opportunities policy which they adhered to. Staff employed demonstrated different backgrounds, ages, genders and ethnicity which was a benefit for the people they supported.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

There were governance systems to help identify and address any issues. These systems covered key areas such as care plans, falls and medicines. However,there were no issuesidentified,by the registered manager who scored everything as 100% compliant. This was inconsistent with the findings of this assessment.

We also found that care plan audits and medicine audits for October and November checked the same people’s plans and medicine records. This mean it was a missed opportunity to review other records. In addition, we found checks for wheelchairs had no dates or manager signature which meant it was not a robust process.

Checks had not identified gaps in recording for pressure care management.

Progress of the action plan in response to our last assessment was not fully completed. Issues relating to recruitment processes and medicines management remained unresolved.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

People and relatives told us they were supported to access other professionals.

A visiting health and social care professional told us they felt people were well cared for well.

The management team advised us of the agencies they worked with outside of the organisation, which included health and social care agencies, and about the benefits to people and the service. This included a care providers association to access training and updates, and other health and social care teams so health care and support were accessible.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

While we noted there had been some progress made since our last inspection, there were areas that had not been fully completed or improved. For example, medicines management and recruitment processes.

Staff told us information was shared and training provided to drive improvements and innovation. A staff member said, “Lessons from incidents are shared and outcomes from inspections are communicated to the team.”

The provider had developed systems to help identify any learning and improvement areas. This included a new HR platform launch which was now used for policy dissemination, communication, annual leave approvals and access to health and safety app. The regional manager told us, “We are currently in process of transferring all recruitment information to this electronic system to enable further remote monitoring too.”

They introduced systems to help improve people’s experiences. This included Buddi interactive activity and therapy system which has an Interactive suite of activities and therapies across all homes now provided via this new system. This was a magic table and floor projection interactive system covering cognitive, music, physio and reminiscence therapy activities.