Highfield House

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 good. At this assessment the rating has changed to 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.

This service scored 61 (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 ensure a stable culture and environment was in place to drive improvements within the service. Relatives expressed feeling uncomfortable with the continued lack of management direction for the service and were concerned about their lack of understanding about who was leading the service. A relative told us, “The manager who was there is gone now and they got our hopes up. But nothing changed.” Another relative commented, “Management is a bit unstable at the moment, the current manager is off, and I am not sure who the manager is which is a bit concerning. They need a permanent manager really.” A relative commented, “If the management team was stable, I would feel better.” Staff however felt able to seek support from the management team and were aware of who to speak with to seek support. The provider told us they had temporary management arrangements in place until they could secure a registered manager for the location.

The provider had not always led the service effectively. Many of the concerns identified at this inspection were related to the lack of leadership presence in the home. For example, reduced compliance with staff training updates, lack of supervision, concerns with staff practice such as daily record keeping and ensuring quality control systems were used. The lack of management oversight along with the current staff vacancies meant there were limited opportunities for people to consistently access an enhanced quality of life and be a part of local communities.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had systems in place to enable people to raise any concerns including a whistleblowing policy. Staff were aware of the process to follow to raise any concerns and felt confident in doing so. A staff member told us, “I have had to do this before and would do this again.”

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 had an equality, diversity and inclusion policy in place which set out how they were committed to ensuring those employed were free from harassment, bullying, victimisation and unlawful discrimination. Staff confirmed they were aware of the provider’s approach with a staff member commenting when asked about equality and diversity being considered, “100% it is a big value of the service.”

The providers systems for management and governance were not consistently used. Whilst the provider had a full range of systems in place designed to monitor the service and ensure improvements were identified and made, these were not consistently effective. The reduced leadership capacity and reduced staffing levels meant some aspects of the provider’s governance systems were not working to identify where improvements were needed. For example, the checks on medicines, staff training, daily records and other areas of concern identified at the time of the inspection had not been identified through these mechanisms. Improvements were needed to ensure a consistent approach to the application of the quality assurance systems.

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. Where needed the provider had engaged with other professionals to provide support to people and develop care plans. Partners told us the leaders were open and transparent when they undertook quality monitoring visits and raised no concerns about the service at the time of the inspection.

The provider did not consistently ensure learning was updated and maintained by staff. The provider had systems in place to ensure staff kept up to date with all mandatory training. However, we found several staff had mandatory training which was either not in place or out of date and required refreshing. This meant the systems were not operating effectively. For example, numerous staff were considerably overdue completing required training/updates in areas such as; first aid, medication administration, Learning Disabilities, Mental Capacity Act, Deprivation of Liberty Safeguards and safeguarding. However, systems were in place to enable the provider to share learning with managers across the providers different locations and the provider shared details of a future project relating to medicines management.