Haighfield Care Home

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 requires improvement. At this assessment the rating has remained requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was in breach of regulation 12 regarding safe care and treatment.

This service scored 59 (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. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Although governance systems had improved since our last inspection, they hadn’t always identified the concerns found during our inspection. The registered manager told us they reviewed any accidents and incidents and looked for themes or trends from incidents and agreed appropriate actions.

People’s risk assessments identified the action staff needed to take to keep people safe, however, people’s care records were not always completed accurately in some areas. For example, regarding re-positioning, personal hygiene and oral hygiene.

People told us they knew how to raise concerns, and most people and relatives said any concerns were addressed. However, one person told us, “Staff brought my breakfast, and it was cold; I asked them to warm it in the microwave, and they said they haven’t got one. They do the second floor first and by the time they get here it can be cold. I mentioned it and for a few days it was hot but gradually it went back to being cold.”

The provider had an action and improvement plan in place, however, concerns we found during this inspection had not been identified and acted upon in a timely manner to drive improvement.

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

Care and support was planned and organised with people, together with partners and communities in ways that ensured continuity. The registered manager ensured initial assessments were completed when people first began to use the service.

The views of people who used the service, partners and staff were listened to and considered. A person told us, “I fell at home and the nurses said I would be better here. When I came in, they [staff] asked questions about my health and did a care plan.” A relative said, “Yes, they [staff] keep [relative name] informed if there is anything they need to know; when I visit, staff offer me a brew.”

People’s needs were communicated with staff when they moved into the service or returned from a hospital stay in shift handover meetings, memos, and communication books. We asked the registered manager how they ensured people received seamless support. The registered manager told us, “We consult external professionals when reviewing care plans. For instance, in creating comprehensive meal and drink plans, which our staff subsequently carry out and oversee. I ensure that my staff members keep in regular contact with these partners. We have a system in place to keep track of and get ready for outside visits. For instance, our nurses are prepared with all the necessary information to guarantee a productive consultation.”

People told us they felt safe. One person told us, “My needs are to be safe, to have company to talk to, good food; all those needs are being met.” A second person said, “The care is wonderful, they [staff] really go out of the way for you, so I feel safe.” The manager told us, “Every employee has received training on whistleblowing. Our transparent whistleblowing policy is also easily accessible for staff. It describes the safeguards in place as well as how to file a concern.”

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.

There were effective systems, processes and practices to make sure people were protected from abuse and neglect. The provider had up-to-date safeguarding policies in place which provided staff with details of how to report safeguarding concerns. Staff made safeguarding referrals when required and leaders identified actions following safeguarding concerns being investigated. The provider ensured external bodies such as the CQC were informed of any safeguarding concerns in a timely manner.

There was a commitment to taking action to keep people safe from abuse and neglect; this included working with partners in a collaborative way. Staff were encouraged to raise concerns and felt confident to do so and there was a freedom to speak up champion in post.

The provider had a deprivation of liberty safeguards (DoLS) policy and procedure. The care records which we reviewed had evidence of DoLS in them. The provider also kept track of who had a DoLS in place and when this would expire. Staff had a good understanding of DoLS. We found any conditions attached to DoLS were being followed.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider was previously in breach of the legal regulation in relation to assessing risk. Improvements were not found at this assessment, and the provider remained in breach of some parts of this regulation.

People had risk assessments for a range of areas, including medication, mobility, nutrition and skin care. However, one person who was required to be hoisted by staff several times each day to ensure skin integrity, was situated in a bedroom which was too small to safely use hoisting equipment. Staff explained why this person was in this room and said they had told leaders about their concerns, but nothing had been done. We raised this with the registered manager and during the inspection, arrangements were made to move this person to a larger room. Therefore, risks to the person and staff had not been appropriately mitigated prior to our raising this concern.

There was no information in people’s care plans regarding their mattress settings, and we found some people’s settings to be incorrect, relative to their body weight. We informed the registered manager of our concerns. Although spot checks of staff practice were carried out to ensure risks were being managed well and staff were following good practice guidance, there was no suitable system in place for assessing this risk to people.

The registered manager told us the top 3 risks identified at present were fall risks, weight loss and wounds and by identifying these risks, the provider was able to manage the risks appropriately and promptly; we found this was not the case regarding mattress settings and unsafe moving and handling environments.

Staff interacted with people and were extremely helpful and friendly and most people we spoke with felt well looked after, with their specific needs being met.

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

The provider was previously in breach of the legal regulation in relation to safety monitoring. Improvements were not found at this assessment, and the provider remained in breach of some parts of this regulation.

Several bedroom doors and an office door were held open with items preventing them from closing in the event of a fire. There were other items of concern from a Greater Manchester Fire and Rescue Service fire inspection report dated 29 May 2025, including several fire doors which were still defective; the registered manager was uncertain who was responsible for responding to the fire service report. During this inspection, the registered manager arranged for the fire doors to be made safe, but it was unclear if any action had been taken regarding the additional items identified in the fire report. We were told dates had now been arranged for this work to be completed.

We also found wardrobes in some people’s bedrooms which were not secured to the wall, presenting an injury risk. We informed the registered manager about this concern who told us they would instruct maintenance staff to carry out this task.

Some positive action had been taken in some areas since our last inspection. At our last inspection, topical creams, drink thickeners and medicines were not stored safely, and the electrical installation report was out of date; improvements had been made, and these items were now stored safely and there was an up to date electrical installation report in place. Safety checks were completed with certification in place, to confirm utilities and equipment were safe to use. Portable appliance testing was up to date and equipment was serviced as required. There was an up to date risk assessment policy in place.

The provider made sure 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.

At our previous inspection we recommended the provider reviewed their staffing numbers to ensure they were sufficient to meet people's care needs safely. At this inspection, we found there was a consistent staff team in place and a staff picture notice board was in place, to assist people to understand different job types. The registered manager told us, “Staff turnover and sickness are at a minimum, which is a clear sign that staff are feeling happier in their roles. I see staff going the extra mile without being asked, such as adapting a meal to a resident’s personal preference or spending extra time listening to them.”

Staff told us the staffing levels were sufficient at the time of the inspection, although more would be required if additional people were admitted. However, several people felt there were not enough staff on duty during the night. One person told us, “If I don’t feel well sometimes it takes ages before they [staff] come; I know they have lot to do. Some are quick and some aren’t.” A second person said, “There used to be [enough staff] but not now; you get used to get used to the carers you get to know, it seems a long night from after tea, when there aren’t as many carers.”

Staff were recruited safely with appropriate checks in place to assess the candidate's suitability to work with vulnerable adults. This included obtaining references, evidence of right to work and DBS checks. Disclosure and Barring Service (DBS) checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. However, some staff recruitment interview forms did not have a clear question and answer scoring system which would help to determine the suitability of the candidate’s knowledge.

Staff had opportunities to learn, and any poor performance was managed appropriately. Systems were in place to induct and train staff and to ensure staff received regular supervision support and regular spot checks to provide further management oversight. Most staff had completed the relevant and necessary training for their roles; however, some training was overdue for a small percentage of staff.

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

There was an effective approach to assessing and managing the risk of infection, which was in line with current relevant national guidance. People were protected as much as possible from the risk of infection because premises and equipment were kept very clean and hygienic, and there were no offensive odours.

Domestic staff completed daily and weekly cleaning schedules and a cleaning chart was used for recording actions each day. Handwritten cleaning charts were filled in, and showed all areas were being cleaned regularly.

Cleaning trolleys were in place and contained a full range of cleaning equipment on them. There was an up-to-date policy on the control of infection, (IPC), which staff could refer to if needed. Staff were trained in IPC and had access to personal protective equipment (PPE); we saw staff wore PPE as necessary during this inspection.

Staff used appropriate cleaning products which were stored safely, and waste materials were disposed of properly, by appropriate contractors. Enough staff were employed to keep the premises clean.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

We found that records were not always completed accurately so we were not assured that people received their medicines as prescribed. For one person we found that a medicine used for chest pain had not been entered onto the electronic medicines administration record (EMAR) on their discharge from hospital. We could not be assured that people in the service always received their medicines as prescribed.

Staff were not always accurately recording when thickened fluids were being given to people at risk of choking and aspiration so we could not be assured that these were being managed safely.

Medicines were stored safely in line with the services policy.

Peoples care plans and medicines records did not always contain the information needed for staff to manage someone’s condition. We found for some people allergy information was missing or incorrect across records. We also found that information used to alert staff to people’s medicines needs was not always correct and contradictory information was held across records. We could not be assured that staff had correct information to support people with their medicines.

For people who had their medicines crushed prior to administration covertly or via a PEG (Percutaneous Endoscopic Gastrostomy) there was not always information available from a healthcare professional to help give medicines safely this way. Where there were instructions on the medicine chart staff told us that they did not always follow these instructions so we could not be assured that medicines given in this way were being managed safely.

The service provided information that showed that not all staff had their competency assessed for tasks related to medicines in line with the providers policy.

Staff recorded the exact time critical medicines were recorded. However, records showed that people did not always have them at the right time. For example, we found the recommended 4-hour time interval between medicines containing paracetamol had not always been observed. This meant there was a risk of overdose and side effects.

Instructions for medicines that are given when required ‘PRN’ were not always person centred. This meant that staff who did not know residents well might not know what signs to look for to indicate someone needed a medicine for example if they were in pain and required pain relief.