Highbury Residential Home

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• 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

This means we looked for evidence that people were protected from abuse and avoidable harm.
At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Good. The provider was previously in breach of the legal regulation in relation to infection prevention control. Improvements were found at this assessment and the provider was no longer in breach of this regulation.

This service scored 69 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. The provider had systems and processes in place to ensure safety concerns were reported, managed and investigated effectively. Regular reviews were undertaken to improve care practice and mitigate further risks. The registered manager told us, “Throughout the analysis of falls incidents, we identified staff were not deployed effectively at handover times. We shared this with staff teams and changed the process for the handover to ensure staff were present at key times. We have had no reports of falls or concerns since changing this practice.” Staff described an open culture and told us they felt able to raise concerns, make suggestions and these were listened to and acted on.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. For example, the registered manager had implemented a robust pre-admission process, including spending time understanding what was important to people and consulting with them, relatives and health and social care professionals. This helped to reduce people’s anxiety during transitions. One relative told us, “The manager carried out a thorough assessment of [Name] needs prior to moving in. We all contributed to that.”

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 did not always share concerns quickly and appropriately.

The provider had clear policies, systems, processes and procedures in place to protect people from abuse, neglect, harassment and breaches of their dignity. Staff had received relevant training and understood their responsibilities to ensure people were safeguarded, including reporting and escalating concerns to the management team. The registered manager upheld their responsibility to ensure people who were deprived of their liberty (DOLs) had a Deprivation of Liberty protection order in place.

We found two complaints by people and relatives regarding personal monies going missing. The registered manager had fully investigated these complaints and provided a timely response to the person and relatives, including reimbursing the missing money. However, the registered managers duty to report these concerns to relevant organisations had not been upheld. We raised this with the registered manager who told us, “After the investigation, I didn’t think it would meet the threshold. I shall report this through retrospectively immediately.” We found no other concerns with the management of safeguarding.

People and relatives confirmed they felt the service was safe. Comments included, “Yes [Name] is definitely safe there, they have settled in well” and “I do feel safe here, the staff make sure you’re safe. I’d happily tell them if I wasn’t.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments were completed which identified the level of risk and provided guidance for staff on how to support people safely. Staff demonstrated they understood the risks people faced and encouraged people to take positive risks to enhance their quality of life. For example, a person wanted to walk to their local shop to buy a paper independently, they had a meeting with the person and talked about crossing the road using a walking frame and the risks with their reduced mobility. It was agreed the person would be assisted by a staff member to reduce the risk of falls, ensuring the person could meet their desired outcome.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider completed regular checks to ensure people’s safety and had protocols and plans in place in the event of an emergency. People were able to personalise their rooms, and we saw they moved freely around the premises as they wished. Relatives told us, “It’s very homely and clean. The atmosphere is relaxed, there’s no pressure there and we can visit whenever we like, day or night.”

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. Staff completed training in areas identified as necessary for the service, including training on how to support people with a learning disability or autistic people and specific training to manage delegated health care tasks safely. Competency assessments were regularly completed with staff members to ensure they could undertake specific tasks safely. There were robust recruitment practices in place and appropriate checks were undertaken pre-employment, including a probationary period to assess staff performance.

We reviewed rotas between March 2025 and May 2025. We found appropriate staffing levels and skill mix was in place to ensure consistency of support and safe care. The registered manager told us. “If we have a situation where a person is unwell or requires extra support, we will add in additional staff to shifts to ensure we don’t compromise support for others.”

Relatives told us there was always plenty of staff in the building when they visited their loved ones. Comments included, “I’ve never gone in and thought there isn’t enough staff no, there’s always enough.” And “There always seems to be quite a few of them on the floor whenever I go in.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Domestic staff and care staff followed cleaning schedules and procedures to help ensure people were protected from the risk of infections. Regular audits were completed to ensure appropriate timely actions were taken by the management team.

The registered manager had environmental improvement plans in place, which were regularly updated and reviewed. Improvements had been made to the food preparation area and ongoing maintenance work had been identified and planned for in the kitchen.

We observed staff wearing personal protective equipment (PPE) for personal care tasks and supporting people at mealtimes. Staff understood their responsibility to ensure these were disposed of appropriately. PPE stations around the home were well stocked and cared for by staff.

People and relatives did not raise any concerns regarding the cleanliness of the home. One relative told us, “I have no concerns with [Name] room or the general environment of the home. It’s always very clean every time I go in.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Staff received training in the safe administration of medicines and were assessed as competent before supporting people. We found some records and processes to ensure medicines were administered safely were not in place. For example, a person who required staff to apply medicine patches directly to the skin did not have a transdermal patch body map in place. This supports staff to ensure the application to the skin was recorded and removal of the previous patch was disposed of correctly. Oral liquid medicines did not always have an opened date recorded on the bottle, and some pharmacy labels were compromised and not legible. This increased the risk of the medicines not being administered in line with the prescriber’s guidance. One person did not have a body map in place for staff to follow when applying topical medicines. This meant staff administering medicines did not always have the appropriate documentation to ensure this was managed correctly. We raised this with the registered manager, who immediately implemented improvements and ensured us risks were mitigated.

Managers completed regular checks to ensure people received their medicines on time and in a safe way. People told us they had no concerns over their medicine management. We observed good medicine administration practice throughout the inspection.