Highfield Care Home

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• 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. This is the first assessment for this service. This key question has been rated 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.

Staff knew how to whistleblow if they needed to do so. The provider valued workforce diversity. There was a clear vision. However, communication needed to be improved to ensure this vision was shared. Management oversight needed to be improved to ensure the quality of the service was effectively managed and improved. Opportunities to learn from staff experience was missed. For example, staff feedback did not always lead to improvement. Notifications were not always submitted to CQC when they needed to be.

The service was in breach of legal regulation in relation to good governance.

This service scored 50 (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 had a clear vision for the service. However, there were areas where improvement was needed to communication within the service to ensure staff and management were working together effectively. One staff said, “Communication could be improved. From everyone, cleaners, nurses, care staff everyone”. The provider told the inspector they had struggled with attendance at staff meetings and staff told us there was a lack of handover meetings. After the inspection handover meetings were reinstated and the provider told us they held a meeting with staff to gather staff on views on where improvements were needed. We will assess if this improvement is sustained and the at the next inspection.

There were some systems in place to support oversight into staff practice, such as reports which could be produced by the electronic records systems. However, these systems had not been used effectively and there was a lack of oversight of the quality and standards of care provided. For example, quality assurance monitoring had not been used to identify people with fluid targets were not meeting those targets or removed fluid targets as needed. Fluid targets are put in place to support people who are at risk from dehydration.

The registered manager and deputy manager were both registered nurses and were therefore able to oversee clinic practice within the service. However, there was insufficient oversight of staff practice within the service. The registered manager told the inspector they spent 3 days per week at the service providing oversight. They were supported by a deputy manager. However, they too had other responsibilities and undertook nursing shifts at the service working as a full-time nurse.

Staff knew how to whistleblow if they needed to raise concerns to the provider or outside of the organisation. The provider visited the service on a regular basis and staff spoke with them whilst they were there.

However, there had been some alternative routes of feedback from staff which had not been acted upon and opportunities to improve had been missed. For example, staff had raised concerns that morning handovers were rushed during a mock inspection which had taken place in January 2025. This had not been further investigated and issues in relation to communication identified had not been resolved.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for staff who worked for them. Staff could access reasonable adjustments if they were required. The service celebrated a range of religious and cultural events to reflect both the people that lived there and the staff who supported them.

The service did not have good governance. They did not act on the best information about risk, performance and outcomes where possible. Quality assurance systems had not always led to sustained improvements. For example, the provider commissioned a mock inspection in January 2025 from an independent company. Where the report had recommended action or highlighted action was required, we found the issues had not always been addressed.

Quality assurance systems had not led to care plans being complete and accurate. Whilst care plans were marked as being regularly reviewed, we found areas where they needed to be amended which increased the risk new and agency staff would not know how to consistently support people safely and effectively.

Governance systems were not effectively reviewed to support the registered manager and provider to identify trends where improvement was needed. For example, there were patterns of when some regular checks on people did not always take place such as checks on people’s welfare in the morning. These gaps aligned with staff feedback regarding staffing pressures in the morning. One staff had told us, “It’s a bit busy in the morning. A bit too busy.”

Notifications were not always reported to CQC when they needed to be. It is a legal requirement for services to inform CQC of certain events such as incidents which involve the police or safeguarding. These events had not always been reported prior to the inspection.

Staff 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. Staff worked alongside other services such as the GP practice, speech and language team and occupational health services to ensure people had access to the healthcare and services they needed.

The provider had not focused on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. Improvement was needed to develop a learning culture within the service where the tools available were effectively utilised to identify and drive forward improvement. In response to the inspection the provider did send us an action plan for areas of improvement based on the feedback we provided. However, there had been a lack of proactivity in identifying where improvement was needed.

Best practice tools, to gain insight into the experience of people who were not always able to express their views, were not always used. For example, management had not considered how some people were seated in the dining room might impact on their mealtime enjoyment.