Highfield Residential Care Home

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 regulation in relation to the governance of the service.
 

This service scored 54 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

A clear vision and culture was not always evident. Although people were happy with the care they received and felt staff knew them well and treated them with kindness, the concerns found during the inspection did not evidence a shared vision and goal to provide good quality care within a safe and pleasant environment. This included the cluttered and unclean areas around the home, issues with medicines management and the lack of robustness around learning from incidents.
 

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

Staff, people and relatives were complimentary about the registered manager, including their approachability and support. Some people knew the registered manager and were comfortable chatting with them and sharing concerns. Comments from people included, “Yes I can talk to her if I have any concerns”; “She is very approachable, a real people person” and “I know of her, but I can’t remember her name.” Staff told us, “(Registered manager) is fairly new, about 1 year, and she is trying her best to be supportive."
However, the registered manager was not aware of some of the concerns we raised during the inspection visit and the management team and staff had not identified and raised concerns around the environment. Staff shared concerns around medicines management with the inspector, but the registered manager was unaware. There were conflicting accounts about how long the issues had been present and if action was being taken to address them.
This suggested that although leadership was visible and approachable it did not lead to continuous improvement in standards.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they knew they could speak up if they had concerns about people’s safety. They were confident they would be listened to and action would be taken.
People and relatives felt equally confident to raise concerns if they had them. People commented, “Yes I would and have done in the past (raised a concern)” and “Yes I would talk to the staff.”

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 fed back that the culture in relation to the staff team was fair and inclusive. We observed a happy workforce who went about their daily tasks with a smile. We saw staff sitting chatting with people and people told us they were not rushed. This suggested staff were not under pressure from the management team.
Staff said the registered manager was flexible if they required a change in work pattern for a time if needed due to personal circumstances.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes.

The provider did not have a clear oversight of quality and risk in the service which meant people were at risk of receiving unsafe and poor quality care. The provider’s systems to monitor and improve the safety and quality of care provision were not effective. Monitoring and auditing processes were unsuccessful in picking up issues within the service, or in taking action when issues were found.
The registered manager told us they had made many changes and improvements since starting in post in May 2025. However, we found many concerns that should have been identified and acted upon sooner. There was a reliance on the registered manager completing the majority of regular audits. This meant an objective opinion was not always apparent to ensure the quality of the service. For example, the registered manager developed and reviewed the majority of people’s care plans. They also undertook an audit every month of care plans, meaning they were checking their own work. No issues were found with any care plans each month. However, we found areas that needed to improve.
The registered manager completed a monthly medicines audit. We reviewed each audit back to January 2026 and no areas for improvement were found across those months. A random selection of 3 people’s medicines were selected each month by the registered manager to check they were safely managed with no errors. In January, April and May 2026 the same 3 people’s medicines were selected. This meant the provider could not be assured each person’s medicines were checked for safety. The registered manager told us the deputy manager also undertook a monthly audit when they were ordering and receiving the new stock. However, this was not recorded so was not evidenced. The deputy manager told us they did random checks through the month, however, they did not record these either.
Environmental audits and infection prevention and control audits were completed each month, however, no issues were noted. We found a number of issues in these areas.
We found concerns around people’s privacy and personal information. Records in relation to daily interventions completed by staff with a person now deceased were found in a communal place that could be seen by anyone walking past. The deputy manager removed these as soon as we drew their attention to it. However, the records had not been noticed by any member of the management team or staff prior to this. Staff had downloaded the electronic medicines management application onto their personal mobile phones and using this to administer medicines. Staff told us they were advised to do this some months ago due to “glitches” in the electronic application causing delays when administering medicines using the supplied devices. Staff said they were under the impression the management team were aware of the technical issues and “the technical people are looking into all that.” The registered manager told us they were unaware staff were using their personal mobile phones due to issues with the system and told us there were no issues with supplied devices. The provider did not have a policy to support the decision for staff to use their own personal mobile phones for sensitive work business to ensure safety guidance was in place. The registered manager advised us after the inspection staff had been told they must not use personal mobile phones and to use only the devices supplied. However, people’s personal data had been compromised for an extended period, and the practice was not identified and rectified.
The provider visited regularly, however, the visits were only recorded every 4 - 6 months. Limited information was recorded in relation to a concentration on the quality of people’s care and safety. Checks on the audits completed by the registered manager were not evidenced to ensure a robust overview of quality and risk. Opportunities were missed to improve the standard of care by ineffective quality assurance. The provider told us after the inspection they intended to change their monitoring processes to provide a more robust approach.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The registered manager engaged with community healthcare staff to support people’s health needs and benefit their health outcomes. Staff partnered with external entertainment providers to support people to participate in meaningful activities to add some enjoyment in to their days.
There was limited engagement with other external partners to share ideas and gain added support to improve and innovate.
 

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

A learning culture was not always embraced to ensure safety was a priority. Accidents and incidents were not always effectively monitored to learn lessons to prevent further occurrences. Although the registered manager completed a trends analysis in relation to people’s falls, other accidents and incidents, such as when people experienced distressed or anxious behaviour had not been analysed to enable learning to prevent future incidents.
The analysis of falls had identified a possible theme over a period of 3 months, including the same staff being on duty at the times when the majority of falls occurred. However, no action had been recorded as planned or taken. This meant the analysis was ineffective in learning lessons and making improvement to support the quality and safety of people.
There was limited evidence staff had 1:1 supervision over the last 12 months. Out of 13 care staff, 2 senior care staff had an appraisal meeting in May 2026. There was no evidence that any other care staff or senior care staff had an appraisal or supervision meeting before or after this up to the time of the inspection visits. The provider’s supervision and appraisal policy states this should be a 3 monthly meeting. An opportunity was not taken to check on staff performance and development. This would provide assurance staff were learning from experience and had the attributes, training and skills needed to provide good quality and safe care to people.