Highfields Nursing 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

There were clear and effective governance, management and accountability arrangements. Staff understood their role and responsibilities. Managers accounted for the actions, behaviours and performance of staff. The systems to manage current and future performance and risks to the quality of the service took a proportionate approach to managing risk that allows new and innovative ideas to be tested within the service. Data or notifications were consistently submitted to external organisations as required. There were robust arrangements for the availability, integrity and confidentiality of data, records and data management systems. Information is used effectively to monitor and improve the quality of care. Leaders implement relevant or mandatory quality frameworks, recognised standards, best practices or equivalents to improve experiences and outcomes for people using services.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a service improvement plan in place to track developments and ensure the required measures were taken to maintain and improve the service to a high-quality standard. The management team all had responsibility for ensuring these actions were completed. The manager and care and compliance group director acknowledged there were areas which were still being improved and required embedding as the new manager settled into their new role. We saw the manager was being supported by the care and compliance group director to improve their management skills and knowledge. The care and compliance group director and staff team had confidence in the manager’s skills, knowledge and approach.

Acknowledging previous shortfalls in the quality of care provided, which we found at our previous inspection; the management team had worked hard to ensure they now had improved systems in place to deliver a positive experience, and good quality of life for people.

The manager and deputy manager had a positive working relationship, which they worked hard to embed across the staff team. Our observations of their interactions with people, relatives and staff during the site visit indicated they were dedicated to improvement. One member of the management team told us, “The residents will always come first, we will always help out anywhere needed. The staff need to know that their management team are supportive.” The provider had given their full commitment to investing in the service, acknowledging previous shortfalls found and ensuring a robust approach to improvements.

The service had plans in place to further improve the living environment for people. The care and compliance group director had a service improvement plan in place with a tracker for progress. Allocated tasks and regular auditing were being completed by the management team regularly to assess progress.

The service had a clear whistleblowing policy and process in place for staff. The management team operated an open-door policy and there were no indications of a closed culture at the service.

The complaints process in the service was clear and was displayed in the main entrance. We saw the management team had reviewed and analysed themes and trends of the complaints or concerns received. The manager could demonstrate how they would prevent similar issues from happening again, as they had learned lessons from previous outcomes.

The manager and deputy manager actively encouraged workforce participation and engagement. We saw there were regular staff meetings and handover meetings. The manager gave feedback around the positive culture they worked hard to create and embed within the service. There were multiple avenues available for staff to raise concerns with the management team or externally, either formally or anonymously. We saw the group care and compliance director regularly completed audits which covered the required regulatory and commissioning standards. Included in this was seeking regular feedback from people, relatives and staff. If any concerns had been raised, we saw these had been addressed by the management team.

The management team showed a good knowledge and understanding of workforce equality, diversity and inclusion within their recruitment process. All staff had completed training in equality and diversity and understood the importance of respecting differences and ensuring an inclusive workplace.

The service had a business continuity plan and good quality emergency plans in place. The group care and compliance director explained how the provider was committed to investment in the service and staff team to ensure future service development.

There were irregular audits taking place of people’s care plans and daily records which meant the management team had no effective oversight. Therefore, people were placed at risk of having unmet needs. The actions taken by the management team after our assessment visit to improve the processes in place for reviewing this documentation provided assurance this had been addressed. The manager ensured the governance systems and processes in place to manage risk were effective. There was accident, incident, falls and call bell analysis in place which had been utilised to identify themes and trends to inform them of how to improve support and safety for people. The management team showed evidence of lessons learned and improvements being implemented as a result of incidents that had occurred. The manager had ensured they reported notifiable incidents to the CQC as required by law.

People and their relatives felt involved in the service and able to share their views. We saw the management team sought regular feedback from people, relatives and staff, to ensure they were active participants in shaping the service. We saw one relative had given feedback, “The manager and deputy are brilliant. Nothing is too much trouble.” And another relative had stated, “I go home knowing my family member is safe.”

Staff felt able to speak with the management team to share their views and raise concerns when they needed to. The manager, deputy and group care and compliance director were open and transparent, and showed a candid approach during our site visit. A staff member told us, “The manager is a positive person. They care about people so much. They always do their best and did so in the role they were in before they became a manager.”

We received positive feedback from partner agencies regarding the service and their approach to external engagement.

There was evidence of effective partnership working at the service. There were systems in place to ensure professional input was sourced in a timely manner to improve outcomes for people. People who were at high risk of falls had referrals made on their behalf to support risk mitigation. External health team information regarding diabetes and nutrition support management was included in people’s care plans, ensuring their needs were effectively met. Contact with relatives was recorded. Incident records, such as falls events, included information about whether relatives had been contacted about the incident and any subsequent actions taken. It was clear the manager was following the duty of candour.

One staff member told us, “There was previously a culture of 'new starters', I can't work with them, they don't know what they are doing. So, we discussed as a staff team how can we fix this? We came up with a buddy system, with other staff nurturing them. So, staff could go to their buddy and ask if they had forgotten how to do something. If you are new to care or a service, there is a lot to remember, so this has really helped. The only way teams are going to improve is if you share skills and knowledge.”

The management team demonstrated a commitment to continuous learning and improvement across the service. The manager had carried out reflective supervision and learning with individual staff where incidents or near misses had occurred. This ensured care quality and staff practice could be improved. The management team ensured they had systems in place to deliver a quality experience, positive outcomes and good quality of life for people. The provider had improved the living environment for people. The management team had a service improvement plan in place to ensure people’s care provision at Highfields Nursing Home remained safe and effective.