Highmarket 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.

The service was in breach of legal regulations in relation to governance at the service which included record management.

This service scored 62 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff were aware of the values of the organisation and described a positive working culture of teamwork. The provider sought feedback from staff via staff meetings and anonymous staff surveys. Feedback from people and their relatives is also sought, this meant there was a culture of collaboration where people could raise any issues.

The provider demonstrated an inclusive culture, and was person centred, all staff received face to face and online training in equality, diversity, and dignity.

People lived in a care home which had a registered manager in post. However, the registered manager oversight of the service was not always effective, as they had not always had sufficient support to develop and embed their roles and responsibilities. Staff provided mixed feedback, stating at times there is a lack of equipment such as correct sized gloves, soap, and sanitiser. We observed essential PPE was stored in locked rooms which hindered the timely availability of PPE. People told us that they saw the registered manager at the home, and they were approachable and responsive. One relative told us “The manager is accountable, the medical team are approachable, and they all know what they are doing.” Another relative commented, “They always email if there is a change in family member’s medication or something like that. They phone up too if [person] has been involved in an incident such as a bang on their elbow which recently occurred.”

Relatives said the registered manager demonstrated a caring approach and was available if they needed to discuss any aspect of their family members’ care.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People told us they would feel comfortable speaking up if they were dissatisfied and were confident any concerns they raised would be listened to.

Staff told us they knew how to raise concerns. One staff member said, “I have no hesitation about whistle blowing, I know exactly what to do.”

The provider had a whistleblowing policy in place which gave clear guidance to staff about how to raise a concern and information regarding whistleblowing was on display in the staff room.Staff and relative surveys also took place. Staff supervisions took place regularly where people said that they could raise their concerns.

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.

Staff told us how they had been supported to take on new roles and responsibilities within the provider’s range of services. One member of staff told us they were valued as they had support from the management team and had opportunities for training and career development.

People were supported by a diverse group of staff which represented the local community. The provider’s policies and procedures supported an inclusive culture where all people and staff were respected, and their differences celebrated.

The provider's systems in place were not always routinely effective to identify areas for improvement. They did not always act on the best information about risk, performance, and outcomes.

The provider failed to establish and operate effective governance systems to enable them assess monitor and improve the service. For example, some records relating to each person were not routinely and consistently complete or recorded at the time of the care or support, which had the potential to put people at risk of harm.

The registered manager and provider had a range of audits and checks in place to monitor the service and drive improvement. However, we found these were not routinely successful identifying gaps. Where audits did identify improvements, we found there were delays in action being taken.

Where required, the provider submitted notifications to the CQC and made appropriate referrals to relevant stakeholders.

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 was integrated in the community it was in and was considered a valued partner by others in the community. For example, the home is veteran friendly and provides a space for monthly British Legion meetings.

People told us the home invited the public to take part in their events such as knit and natter group, the senior lunch and bingo club and dog café. Events in conjunction with external organisations were held at the home which relatives and the public were invited to attend, examples of this are a Stroke Association launch day in conjunction with the Stroke Association and a diabetes information session. Charity events regularly take place at the home.

People told us that the home has a ‘open door policy’ during the cold winter months so the public could use the home as warm space.

The provider focused on continuous learning, innovation and improvement across the organisation and local system.

The provider aimed to learn from events such as accidents and incidents. Staff told us any learning from events was shared with them to improve practice and standard operating procedures.

Staff said they were able to share ideas in their supervision meetings and staff meetings. They told us there were good opportunities to learn and develop in their roles. The managerdeveloped and delivered additional training sessions in order to up skill staff in certain subjects.

The provider had plans to introduce an improved digital care planning system and stated that it would be rolled out soon.