Highwell House Care Home with Nursing

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 75 (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 promoted 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.

People and their relatives told us they felt supported by staff, and safe. One person’s relative told us, “The care and environment they provide makes us feel (Name) is safe. The level of care and attention to detail in the care (Name) has received means that (Name) is still with us today.”

Staff we spoke with demonstrated good understanding of the process to report incidents and told us they were encouraged to report concerns. Accidents and incidents involving people who lived in the service were investigated thoroughly and transparently by the provider. Accidents and incidents were reviewed and analysed, with appropriate action taken to reduce the risk of recurrence.

Daily staff meetings were held to discuss people's care needs, identify any concerns, and share learning. These meetings provided opportunities to reinforce best practice and support the delivery of safe, high-quality care.

The provider worked effectively with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They promoted continuity of care, including when people moved between different services.

The provider had a thorough and organised approach to supporting people when moving into the home. The involvement of those who were important to the individual was actively encouraged, helping to ensure a collaborative, coordinated and person-centred start to their experience within the home.

The service was supported with weekly visits from the local GP surgery, this approach helped with effective and timely management of people’s health needs. People and their relatives told us the service understood their health care needs. One relative told us, “They know when (Name) is getting poorly and they manage it well.”

There were clear processes in place to ensure peoples care plans remained accurate and up to date. This helped to ensure relevant information was shared appropriately and continuity of care was maintained when people moved between services.

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.

People and their relatives told us they felt safe. One relative said, “Yes, they are very proactive in her care. I feel she is safe in every way.”

Staff had received safeguarding training and demonstrated a good understanding of their responsibilities to protect people from harm. Staff told us they felt confident raising concerns and were assured that these would be listened to and acted upon appropriately. One staff member told us; “I have completed safeguarding training. I’ve never had any safeguarding concerns but if I did I would take them to management, or if needed the provider”.

An up-to-date safeguarding policy was in place, and safeguarding processes were well organised and effectively managed. A safeguarding log was maintained, clearly recording concerns raised and notifications submitted to external agencies, including the Care Quality Commission (CQC). Monthly management meetings included discussions about safeguarding concerns, lessons learned, and actions taken to reduce the risk of recurrence.

Effective systems were in place to manage Deprivation of Liberty Safeguards (DoLS). These were used only when necessary, in the person's best interests, and in accordance with the Mental Capacity Act 2005. Staff had received training in the Mental Capacity Act and worked in line with its principles, ensuring people's rights were upheld and their choices respected.

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.

Positive risk-taking was actively promoted, with people, and their relatives where appropriate, involved in discussions and decision-making when developing and reviewing risk assessments. Risk assessments were detailed and person-centred, providing staff with clear guidance on identified risks and the measures required to minimise these. They included practical strategies to support safe care delivery while ensuring people's rights, choice and independence were respected.

Records demonstrated that accidents, incidents and falls were thoroughly reviewed to identify any underlying causes and opportunities for improvement. Appropriate action was taken to reduce the likelihood of recurrence, and learning was shared with staff to strengthen practice and promote continuous improvement. This proactive approach helped keep people safe while supporting positive outcomes and maintaining their quality of life.

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

One person’s relative told us; “They have created a homely environment that residents feel safe in, it is their home”.

The home environment was exceptionally well maintained and presented to a high standard. Communal areas were clean and tastefully decorated, with furnishings that were both comfortable and suited to people's individual needs. The environment was safe, accessible, and supported people's independence. People were encouraged to personalise their bedrooms with their own furniture, belongings, and personal items, helping to create a familiar and homely atmosphere while promoting choice and individuality.

The provider had invested in enhancing the outdoor environment. A well-maintained garden with accessible pathways and seating areas was available for people to enjoy. People were supported to participate in gardening activities, including growing strawberry plants. Further development of the outdoor space was underway, with people involved in its design choosing the plants and flowers they wanted, helping to create an environment that reflected their preferences.

Records evidenced that equipment necessary to support people's safety and independence, including wheelchairs and walking aids, was routinely checked and maintained to ensure it was safe and suitable for use. Comprehensive environmental checks were undertaken to monitor and manage risks, including water, electrical, and gas safety. Effective fire safety arrangements were in place, with staff undertaking fire safety training and participating in routine fire drills.

The provider ensured 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 had safe and robust recruitment processes, appropriate pre-employment checks were carried out to ensure only suitable staff were employed. Staff completed a comprehensive induction programme, and a training and competency matrix demonstrated that mandatory training was up to date, and staff had the skills and knowledge required to meet people’s needs effectively. People and their relatives spoke positively about the quality of care staff delivered and their knowledge. One relative told us; “They go above and beyond with the care. He is still with us because of them and the way they care for him and the understanding they have about him.”

Staffing rotas showed appropriate staffing levels across all shifts, supporting the safe and consistent delivery of care. Staff, people and their relatives provided positive feedback about staffing arrangements. One relative told us; “(Name) has never raised any concerns, and I haven’t seen anything to concern me.” During the inspection, we observed staff present in communal areas engaging with people and responding promptly to those in their rooms. People did not appear to experience delays when requiring assistance.

The provider thoroughly assessed and managed the risk of infection. They always quickly detected and controlled the risk of it spreading and always shared concerns with appropriate agencies promptly.

People and their relatives consistently told us the service was clean and hygienic. One relative said, “It's very clean and hygienic,” while another told us, “It's absolutely spotless.”

The provider demonstrated effective infection prevention and control (IPC) systems that were embedded within daily practice. Staff had clearly defined roles and responsibilities in relation to IPC, including an Infection Control Lead, a Cleaning and Decontamination Lead, and four IPC Champions.

The IPC team took an active role in promoting and monitoring good practice across the service. Their responsibilities included completing and reviewing IPC audits, ensuring identified actions were addressed, raising awareness of IPC issues among staff, people and visitors, and supporting staff through education and training. This helped to promote a positive culture of infection prevention and encouraged continuous improvement in practice.

The registered manager maintained effective oversight of IPC through the completion of an annual IPC statement, reviewing the effectiveness of existing systems, identifying areas for improvement, and ensuring lessons learned were embedded into practice.

During the inspection, we observed a clean, well-maintained environment that was free from malodours. Staff had access to appropriate personal protective equipment (PPE) and were observed following IPC procedures. Handwashing facilities and bathrooms were well stocked, supporting good hygiene practices for staff, people and visitors.

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.

Robust medicines management systems were in place to support the safe handling, administration and storage of medicines. Medicines were stored securely, with regular temperature monitoring undertaken to ensure appropriate storage conditions were maintained.

Care plans provided staff with detailed guidance on people's medicines support needs. Clear protocols were in place for medicines prescribed on a PRN (‘as required’) basis, such as pain relief or medicines to support people during periods of distress or agitation. Controlled drugs were managed safely, and records were accurate, up to date and regularly audited, supporting effective oversight and accountability. Medicated creams were administered appropriately, with oversight from senior staff, and people received their medicines as prescribed and when required.

Staff responsible for administering medicines had completed the necessary training and competency assessments, which were up to date and enabled them to carry out their roles safely and effectively.