Higher Bank

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 changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to safe care and treatment including risk management, medicines management, governance, safeguarding and safe staffing specifically relating to staff training.

This service scored 34 (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. Lessons were not always learnt to continually identify and embed good practice.

Professionals provided mixed feedback around learning culture. Whilst one professional said, “The provider works well with us and takes appropriate action when things go wrong”, another told us, “On the whole, yes (they work with us). However, because we are not always notified of safety issues in a timely manner, we do not always have the opportunity to provide proactive support.” There were limited records regarding lessons learned and how these were shared with staff.

People and their relatives suggested there was an open dialogue of communication with the management and staff in the home, and staff knew how to report concerns. Records indicated accidents and incidents were being recorded in an accident book.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety.

Professionals provided mixed feedback on in this area, one professional said, “The service does ensure continuity of care between us,” whilst another noted that, “We get very limited contact from this home and therefore information is not available to provide a full response. However, when attending wider meetings with relevant professionals such as district nurses, infection control etc as part of the monthly combined quality meeting, there is feedback that (other) partners also have very little engagement with the home.”

We were able to see examples where appropriate referrals had been made when people needed external support, though this was not consistent as covered in more detail, throughout this report.

People and their relatives felt the staff team worked well together to ensure they received the care and support they needed. Staff spoke about information being shared at handover. One staff member said, “Every morning when we comeon,we havehandovers and every night.”

The providers safeguarding practices were not robust and we were offered little assurance about safeguarding. The provider did not share concerns quickly and appropriately. Records relating to safeguarding and mental capacity were not robust and were not readily available. The providers practices were not always safe.

Staff were not knowledgeable about who or if anyone in home had a Deprivation of Liberty Safeguard (DoLS) in place. A Mental Capacity and DoLS policy and procedure was in place, though this had not been dated, signed or reviewed. Records were not available for us to review on site in relation to people’s DoLS assessments, so we were not assured that appropriate DoLS referrals had been made. Some DoLS applications were later shared with us, but we were not assured if all necessary referrals had been made for people.

Although there was a signing in book, we found this was not consistently being completed, as prior to our signing in, the last entry was 27/05/2026, but we were aware visitors had been in the home after this date. This meant we could not be assured the home had accurate records of visitors to keep people safe and secure, and the provider was not complying with their visitor’s policy.

No recent safeguarding referrals had been made by the home at the time of the inspection. We were told that a recent safeguarding had been raised by visiting district nurses, but one of the registered managers was not able to provide any supporting documentation in relation to this. The service had a safeguarding policy in place, though this had not been reviewed since September 2024. Following our onsite assessment, we raised a safeguarding due to multiple concerns we identified onsite.

Staff were generally knowledgeable about safeguarding, though based on the records available to us, not all staff had recently completed safeguarding training in line with the providers own policy.

People told us they felt safe and their relatives told us they believed their loved one was safe. One relative said, "Yes 100% (I think my relative is safe here)."

The provider did not always work well to understand and manage risks. We were not assured that the care being provided was safe and supportive.

Whilst risk assessments were generally in place relating to people’s health and the associated risks, we were not assured risk was adequately mitigated for those at risk of choking. Records showed the appropriate actions were not always taken when someone was observed to have eating and drinking difficulties, and staff we spoke to were not able to differentiate those at greater risk of choking. A staff member said, “I think everyone is (at risk of choking), that’s how I see it.” A registered manager advised they felt the staff response appropriate, as they said everyone is at risk of choking.

Staff could explain how they supported people communicating a need, emotion or distress. One staff member told us, “A few (people) can become anxious but not challenging, we reassure them and tell them what we are doing.”

We found everyone had a personal emergency evacuation plan (PEEP) in place, though some of these records lacked specific detail. For example, we found two people who required the use of a hoist and sling did not have this detail in their PEEP. People’s relative’s felt people’s risks were being managed, and environmental risk assessments were in place.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Fire safety checks were in place. However, we could gain no assurance staff were up to date with fire safety training. Staff gave differing accounts of where the fire safety evacuation point was, and a staff member told us they had not attended a fire drill.

The environment needed improvements to ensure people’s safety. For example, some windows required restrictors fitting and some radiators required covers fitting. We also found water temperatures in some water outlets ran too high which increased the risk of scalding.

Equipment in the home was not always serviced in line with Lifting Operations and Lifting Equipment Regulations (LOLER). Although a legionella risk assessment was in place, we gained no assurances that this had been completed by a fully competent person.

The environment was not neutral and had heavily patterned carpets and wallpaper, which could cause disorientation to people living with dementia.However, this did not currently effect people living at this service and in some cases, people had chosen their wallpaper in their bedrooms which promoted a more homely feel.

Doors had images on that had been chosen by the person who resided in the room, which made the rooms recognisable to them. Bedrooms were personalised with items important to people. People and their relatives felt they/their loved one was in a safe environment.

Following our onsite assessment, a registered manager advised they had started making the necessary improvements in relation to the above concerns.

It was not clear how the provider ensured there was enough qualified, skilled and experienced staff. It was not clear how they made sure staff received effective support, supervision, development and training.

Records indicated staff training was not up to date in multiple areas. Following the inspection a registered manager told us staff had now started to complete necessary courses.

The home did not use a dependency tool to help calculate staffing levels, so it was difficult to determine if staffing was appropriate. Agency staff were occasionally being used to help ensure staffing levels were consistent. The home requested the same agency staff member to ensure consistency for people. People and their relatives felt there was enough staff. Staff told us they felt there was enough staff.

Records indicated staff supervisions and appraisals were taking place, though conversation with staff did not always reflect this, a staff member told us, "I haven't had any supervisions or appraisals in the last 12 months." Whilst another staff member said, they “Had 1 to 1’s with the manager once a year.”

Safe recruitment practices were mostly being followed, and appropriate checks were made, though interview records were not in place for the files we reviewed.

Although the provider ensured the home was clean and tidy and consideration had been given to infection control, records were not always robust relating to this.

Cleaning oversight records were not consistently being completed in some areas and daily kitchen cleaning records needed to be more robust; a registered manager implemented a new daily kitchen cleaning record during our visit.

People felt the home was clean. One person said, "Yes, of course it is clean." Staff told us how they prevented or controlled the spread of infection. One staff member said, "I use PPE, I clean, we use red bags for laundry." The home was clean and tidy and there was a dedicated area for laundry. Appropriate PPE was in place.

The provider did not make sure that medicines practices were safe and records relating to medicines were not robust.

Controlled drugs were not being safely managed. There was no thermometer in the room used to store controlled drugs or in the controlled drugs cupboard; and controlled drugs stored in the home had not been recorded in a controlled drug register.

Various prescription labels were faded and illegible, making it difficult to determine if records relating to prescriptions were correct or being followed. Liquid medication bottles were not always dated when opened to ensure they could be disposed of in line with the manufacturer’s recommendations. It was not always clear who administered medication or topical creams due to differing accounts.

A registered manager had changed a person’s medication administration time for one of their medications without GP input. They told us they would revert back to following GP instructions. Medication which required specific intervals between doses did not detail the exact time of administration, meaning we could not be assured there was adequate time between administration. This placed people at risk of an overdose.

Medication records were not always as detailed as they needed to be, a registered manager spoke with the pharmacy following our onsite assessment to help rectify the issue. We were not assured staff who administered medication had completed the necessary training, and competency checks were not always completed in line with best practice.

There were multiple medication policies, and it was not clear which was the most up to date version being used. Medicines audits were not robust and were not being appropriately completed.

Most medication counts were correct, and people’s medication patches were being appropriately positioned to avoid skin irritation.