Highwood Mill Extra Care Scheme

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.

This service scored 57 (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, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Ineffective audits and inaccurate care plans meant the service was not fully effective in learning and improving. These gaps limited the provider’s ability to embed good practice and consistently deliver care in line with its vision.

Staff and leaders, we spoke to shared a common goal of ensuring people received good care. The provider had organisational strategy, policies and procedures in place to support organisational culture, although leaders acknowledged this needed further development.

The service worked to embed values through team meetings. Staff told us of improvements in clarity of leadership and communication over the past six months. One staff member told us,” The culture is now about a 9 out of 10 compared to 2 or 3 previously.”

Leaders had some knowledge and understanding of issues and priorities within the service and there was evidence some issues and poor practice had been addressed since the last inspection.

More office staff had been employed, and roles had been more clearly assigned. These roles and the new business structure required further embedding.

People told us leaders were not always visible, approachable and supportive as the registered manager oversaw another service and split their time between the two services.

One person said, “I have been downstairs on many occasions and there has been nobody there.” Improvements were needed to ensure leaders had a clear oversight of the service provided at Highwood Mill.

This meant there was a lack of oversight of the service, which limited the registered manager’s and provider’s ability to identify and act on risks, learn lessons, and fully drive improvements.

The leadership team carried out spot checks and provided feedback and training where needed. We saw evidence of the provider sending emails to leaders regarding checks and audits carried out by heads of departments. For example, there was an audit regarding empty sections of care plans and leaders were reminded that these needed addressing.

The provider fostered a positive culture where people felt they could speak up.

There was a culture of openness where staff and residents felt able to raise concerns without fear of reprisal. Staff demonstrated understanding of safeguarding and whistleblowing processes, and posters and policy refreshers were in place. One staff member explained, “They’ve always told us… tell us what we’re doing wrong.” Residents confirmed they knew who to contact if they had concerns and felt confident issues would be addressed.

The provider generally acted on concerns raised by relatives and worked collaboratively with the local authority to resolve issues, such as medication errors and care planning gaps.

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.

The provider promoted equality and inclusion, though some challenges remained in managing agency staff and cultural expectations. The provider addressed discriminatory behaviour from residents towards agency staff through formal letters and safeguarding referrals, demonstrating commitment to a respectful environment.

Staff reported access to wellbeing support and open discussions during supervision.

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

There were some significant gaps in audits at both registered manager and provider level, resulting in issues not being identified and addressed.

Improvements were needed to ensure the provider followed their newly implemented governance structure and associated processes. The systems had failed to identify a number of the concerns found during this assessment. For example, the shortfalls around medicine administration and storage were not addressed. This demonstrated that governance systems and medication audits were not effective in identifying and addressing risks.

While people told us they were generally happy with the care provided and regular staff knew their needs, risks were not being managed. For example, a person’s care plan stated the person was waiting for medical intervention when in fact it had happened some months before the assessment visit. This meant the support the person needed had significantly changes and this was not recorded. The lack of appropriate recording and storing around people’s medications created potential risks throughout the service.

The lack of robust governance systems and accurate records increased the risk of inconsistent care, particularly when unfamiliar staff were providing support. It also limited the service’s ability to evidence monitoring and continuous improvement, especially given the same shortfalls had been identified since the last inspection.

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.

The service worked in partnership with local health professionals, such as Occupational Therapists, District Nurses and GPs.

We saw evidence people received timely medical intervention when required, and the provider submitted examples to us to demonstrate them involving specific stakeholders for a person with complex needs.

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.

We found new systems had been developed and were currently being implemented; however, these were not yet fully embedded, and as a result, had not identified all the issues we found.

The provider felt recruitment in office staff and the leadership team was required. This had allowed specific roles and tasks to be assigned, and a new business structure to be designed. Again, this still required some further development and embedding for it to be fully functional and to operate effectively.

The appointment of the deputy manager had seen oversight at the service begin to improve, and they had co-designed a variety of trackers and spreadsheets to ensure detailed records could start being kept.

During the assessment, we found leaders to be receptive to issues raised, and responsive in making immediate changes to records where required. All leaders assured us they had taken our feedback seriously and showed a collective and positive approach to continuing to drive improvements across the service.