Highfield Residential 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 good. At this assessment the rating has changed to 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 service was in breach of legal regulation in relation to people’s safe care and treatment including the ways people’s medicines were managed safely.

This service scored 47 (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. Staff did not always listen to concerns about safety and did not always investigate safety events. Lessons were not always learnt to continually identify and embed good practice.

Accidents and incidents had not been effectively monitored and analysed to identify themes, mitigate risks and prevent further occurrences. The registered manager had a process in place to monitor falls, however, incidents of people displaying anxious and distressed behaviours were not monitored. Staff recorded when a person was distressed, causing anxiety to themselves or others, using an ABC record. The purpose of the record is to document what led up to the behaviour (antecedent), a description of the behaviour (behaviour) and what happened next, what worked or did not work (consequence). Staff were completing only the behaviour part of the record which meant vital information was missed. The provider did not ensure a process was in place to monitor the ABC records and identify information to develop more comprehensive care plans. An opportunity was missed to ensure people’s care plans were regularly updated with information gained from learning lessons through good record keeping and monitoring. People were at risk of not receiving consistent support based on what they may be trying to communicate, and therefore incidents repeating, creating increased anxiety. Staff did know people well, however, bank and agency staff were used at times who may not have the same understanding.

There had been incidents around catheter care in late 2025, however, the registered manager had ensured lessons were learnt and measures were put in place to prevent a re-occurrence.
 

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure the records they kept ensured there would be continuity of care, including when people moved between different services.

People’s safety was not always robustly monitored or managed. Risk assessments were not always adequate or been assessed appropriately, reviewed or mitigated. This meant information passed to other agencies such as hospital staff may not contain accurate information. There was a risk people would not receive the support they needed when being supported in hospital, or when moving to another care service. Staff who did not know them may not have the information to provide good care and support because their needs and risks were not adequately recorded.
People had been referred to healthcare agencies such as GP, dietician, podiatrist and community mental health team. Healthcare staff told us they had noted an improvement in how the service engaged with them.
 

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 appropriately.

People and their relatives told us they felt safe with the care and support they received. Comments included, “I am much safer here than I was at home” and “I feel very safe here.”
Incidents had been referred to the local authority in line with safeguarding vulnerable adults’ protocols. Staff had raised concerns when they should, and these had been raised externally.
The registered manager had kept a log of safeguarding referrals made and appropriate action had been taken when necessary.

Where relevant, a Deprivation of Liberty Safeguards (DoLS) application had been made when people had been assessed as lacking the capacity to consent to their care and treatment.

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

Staff did not always have the guidance necessary to provide safe care for people living at the service. People did not always have specific risk assessments to identify individual risks in relation to their particular health conditions and care needs. This meant measures were not always in place to minimise risks.

A person at risk of choking did not have a specific risk assessment in place to identify, assess and mitigate their individual risks. The information recorded in the person’s care plan was conflicting, in parts recording they were on a normal consistency diet and in parts recording they must have a soft diet. The person had instances of coughing/choking when eating and a soft diet was advised as a precaution. A risk assessment had not been completed to ensure staff had the appropriate guidance to follow to mitigate against the risk. Together with the conflicting information in the care plan, risks were not highlighted to ensure safe care.
Some people had a history of seizures, such as caused by epilepsy. Individual risk assessments were not in place to ensure the risks associated with the person’s condition were assessed and mitigated against. For instance, although 1 person’s care plan referred to general guidance in relation to what to do in the event of a seizure, individual risks relating to the person’s condition had not been identified and assessed. Important guidance was missing such as the risk of injury, or sudden unexpected death in epilepsy (SUDEP). This refers to the sudden, premature death of an otherwise healthy person with epilepsy, where no other definitive cause of death is found, and something staff need to be aware of.
A person’s nutrition and hydration care plan highlighted in red that staff were to encourage and record their fluid intake to prevent dehydration. Staff were recording the amounts of fluid the person had taken, however, some days the amount of fluid drank was very low. For example, 2 days in 1 week they drank as little as 300mls each day and the most they drank in a day 1 week was 855mls. There was no evidence of fluid records being monitored to ensure action was taken quickly to prevent dehydration. A target amount of fluid was not recorded so the person and staff were aware of the amount they should aim to drink in a day to prevent dehydration and the health risks associated with this.
Risks were recorded in a care plan for a person with a specific health condition. However, they were not individual to the person and included specific medical terms such as melena (blood in the stool) and epistaxis (nosebleed) and medical interventions such as specific blood tests to take. The advice was not appropriate for a community based setting or to provide guidance to care home staff. There was a risk vital signs of deterioration could be missed as the terms used were not specific to the person, where they lived and how they were cared for.

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

The premises were not well maintained. A relative commented, “One area I feel could be improved is the overall appearance of the home. Some areas are beginning to look tired and dated although I did notice during my most recent visit, following your inspection, that efforts had been made to freshen things up.”
The provider had started a re-decoration programme which was ongoing, but some areas around the home were also not safe. A window in a communal area on the top floor, known as the sun lounge, did not have a window restrictor in place. People could step out onto a balcony area with discarded items causing a trip hazard, as well as open access to a metal fire escape that could pose a serious falls hazard. A door leading into the roof eaves was open which could lead to injury if people tried to step into the void. The room was cluttered with discarded furniture, and the carpet was in need of vacuuming. Staff told us some people whose rooms were on the same floor as the communal area ate their meals in there rather than going down 2 floors to the dining room. We saw people eating their lunch in the room at lunchtime. This meant the risk and potential impact was high in relation to the safety hazards as the room was regularly in use. The experience for people while eating their meals was poor given the standard of the environment.

We found other areas within the service that were unsafe. These issues were not new, and the provider only took action to address them when we raised our concerns for people’s safety. These included another unlocked cupboard with access into the roof eaves and a crumpled and rucked carpet in a sloped corridor area causing a significant trip hazard to people. We saw people walking up and down the slope who were unsteady and required the use of mobility equipment. A very small kitchenette area on the top floor was out of use, and a note was pinned to the door. However, a sliding door into the area was half open, meaning people could access the area, which housed discarded items not being used, including a number of dirty cups, paperwork and old kitchen equipment. The area was also unclean. There were a number of cluttered areas that appeared to have been neglected for some time. These included the dining room kitchen area, counter tops and cupboards. Carpet on the steps leading to the registered manager’s office had sticky tape on the top step covering the edge of the carpet but the tape was rumpled and a potential trip hazard. When we arrived on the 2nd day visit, these areas had improved. The action taken once highlighted meant people could live in a safer and more pleasant environment.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective training, support and development.

Staff had not always received the training they required to meet the needs of people living in the service. Some staff were overdue their refresher training in key areas, including areas where we found concerns, such as GDPR, nutrition and hydration and challenging behaviour. 3 staff who had been working in the service for over 4 months had not completed safeguarding vulnerable adults training. Anti choking devices were present throughout the building. Anti-choking devices are a piece of equipment intended to alleviate choking incidents after basic life support protocols have been attempted and failed. No staff had been trained to use the equipment and when to use it. There was no guidance in people’s care plans about the use of the device. This meant staff may attempt to use equipment they were not trained to use during a life threatening incident, creating a potentially greater risk. The registered manager removed the devices following our inspection.
People and relatives thought there were enough staff, although some said this was not always the case at weekends. Comments included, “They always come when I need them”; “I have my buzzer, they are very good and come when I need them” and “There does appear to be a relatively high use of bank staff, particularly at weekends. This can sometimes cause (my relative) to become agitated due to the lack of familiar faces.”
Staff recruitment was not consistently managed safely. Previous employer references were not always checked to provide assurance they matched the staff member’s application form for dates of past employment. Employment references were not always checked for authenticity. Applications forms contained a full employment history, including dates, staff identity was checked and DBS checks (disclosure and barring service) had been undertaken.
 

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

The risk of infection was not always controlled to prevent spreading. The environment was poorly cleaned and maintained in parts. A cutlery tray in the dining area housed cutlery ready to be used for the mealtime. All the cutlery was unclean. Some of this appeared due to dishwasher stains, for example not being cleaned or rinsed properly, but some were greasy or had food residue on them. We checked with staff who confirmed the cutlery had been cleaned and was due to be used. Staff took the cutlery back into the kitchen to be cleaned again prior to the next mealtime. We checked a tray of drinking glasses, also waiting to be used. We found these also proved to be unclean. Staff confirmed they were due to be used for the next mealtime and took these away to be washed again. There was a risk of the spread of infection amongst people due to the lack of hygiene and cleanliness. Attention to detail in order to provide a safe and good quality service to people was lacking.
Other areas of the service were cleaned adequately. Staff had access to personal protective equipment (PPE) when they were required to use it.
 

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

People’s medicines were not always managed safely. We checked a selection of people’s prescribed medicines. Most medicines we counted as being in stock did not correspond with the numbers that should have been in stock according to the medicines record of signed for administered medicines. People were at risk of not receiving the amounts of medicines they needed to stay well, placing their health at risk.

The provider had an electronic medicines management recording system in place. There were a number of issues which meant we could not be assured that people were receiving their medicines safely or that errors had not occurred. The medicines shown as in stock for each medicine on the electronic system did not tally with the actual numbers of medicines in stock. Only 2 out of 14 medicines checked were showing as correctly stocked. Staff told us this was usual as the electronic system did not always update when a medicine was given and there were often issues. Another member of staff said, "The deputy manager does the full audit. There have been discrepancies, for example stock checks, but that can be down to the network system and not actual errors." We could not be assured that people’s medicines were being managed safely, and errors could be picked up quickly to prevent harm to people from receiving not enough medicine, too many medicines, or had medicines missed. We spoke with the registered manager about this, who said they would investigate.

Following the inspection, we asked the provider and registered manager for assurance of the action taken to ensure the management of people’s medicines were safe. The registered manager responded, however, we were not assured of their response as the investigation did not correctly address the issues we found.