Highbury Nursing Home

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 the same.

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 the systems in place to monitor the quality and safety of people’s care.

This service scored 50 (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 have a clear shared vision, strategy and culture which was based on transparency, equity and engagement. They did not always support staff to understand the challenges and the needs of people.

Staff told us they could see improvements in the service provided since the registered manager had joined the team. The team shared a vision of improvement and better care for people living at the home. The team had worked alongside partnership agencies to make improvements to people’s safety and care. However, they had not always alerted appropriate external agencies of incidents, accidents and safeguarding concerns. There was a focus on learning and improvement. Staff spoke positively about the training and support they had received. However, in practice improvements were needed to ensure a fully effective learning culture. For example, in the quality and accuracy of information shared between shift teams and the recording and analysis of falls and other incidents.

Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

Although staff, people and relatives spoke positively about the leadership team, there were areas in which improvements in their skill and knowledge base were needed. The management team did not demonstrate a clear understanding of local safeguarding procedures and expectations, which meant they had not always worked in accordance with these.. They had not ensured information was shared appropriately with other agencies to help protect people from harm.

Staff told us they felt supported by the management team and by their wider team. One staff member told us, “I enjoy my role and feel supported.” People we spoke with who knew the registered manager spoke positively about them. One person said, “The manager is very good and always checks on us.” Relatives we spoke with also shared positive feedback about the registered manager. One relative said, “If we want to know anything we are always welcome in the office.”

We saw that the management team were visible and accessible to people, relatives and staff during our visits.

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

Staff we spoke with told us they felt confident to speak up if they had any concerns. They also told us they felt concerns raised would be listened to and responded to appropriately. A policy guiding staff on what to do if they had concerns was available and staff knew how to access this. We saw examples of concerns raised by external professionals, which records showed had been investigated appropriately.

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 told us they worked well together as a team and supported each other. The overall staff team supporting people living at the home was representative of the local community population. Staff told us they felt more confident in their roles, having received training, competency checks and support.

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.

Although systems were in place to monitor the safety and quality of care provided to people, they were not consistently effective. Safety systems failed to identify that the safeguarding policy was not in line with local safeguarding procedures. Systems had also not identified that information of concern had not been shared appropriately with other agencies. For example, the template managers used to report incidents of concern were shared to the ICB prompted them to consider if the local authority and CQC should also be notified. In many instances the ‘no’ option had been selected, which was not in line with local safeguarding procedures. There was no evidence checks had been completed on these notifications to ensure they were being completed accurately and the processes followed correctly. There was no evidence that quality checks had been conducted to ensure information recorded and shared in staff handovers was accurate and legible. Although care plans were reviewed regularly, these reviews had not always ensured guidance for staff was accurate and up to date.

The management team had failed to ensure they had a good understanding of the legal and regulatory requirements for installing CCTV prior to doing so. Reviews of capacity assessments and best interests decisions failed to identify they were not compliant with MCA 2005 guidance. Although checks of the home environment were conducted, they had not identified some of the concerns we found.

A service improvement plan showed the management team had done a lot of work with commissioning bodies to address concerns and improve care. However, there was little in the plan to demonstrate how the provider’s own quality assurance systems were informing the plan. The service improvement plan did not evidence that the provider’s systems could independently identify and mitigate risks.

The provider and management team were responsive to the findings of our assessment. The provider told us they would work hard to develop and evidence robust and effective systems to provide better care.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not consistently share information and learning with partners or collaborate for improvement.

The provider assured us they would ensure policies and procedures were updated to reflect locally agreed information sharing. They also told us they would aim to network with other local services to share and improve lessons learned. Incidents which should have been shared with CQC as notifications were submitted in retrospect. We did see some examples of good collaborative work between the service and other health agencies and professionals. For example, an investigation was conducted after a person had raised concerns about their care with an external agency. The investigation resulted in changes made to the person’s care and their room.

The management team needed to apply a more consistent approach to partnership work to ensure more equitable outcomes for people.

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.

The provider had systems to enable continuous learning. However, the systems were not always used effectively creating missed opportunities for learning as well as some successful improvements being implemented. This meant the provider did not always deliver equality of experience, outcome and quality of life for people.

During our assessment, we found continued 3 breaches of regulation which had not been met at our last 2 inspections. Systems to drive improvement had failed to deliver sufficient improvement in these areas.

The provider did not always actively contribute to safe and effective practice. When risk was highlighted by external professionals, the management team was responsive. They worked alongside others to improve care and reduce risks. There was much less evidence of internal systems generating learning and improvements to share with others.

We shared these observations with the provider, who assured us they would work to improve systems to create a positive learning culture.