Hightown Road

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.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Staff knew what incidents to report and how to report them and they told us they were confident there was a culture of safety within the service.

The service investigated incidents thoroughly and shared outcomes with relatives and professionals. We saw evidence of change as a result of incidents that had occurred.

The service 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. One relative told us, “My relative was living at home before they moved to the service. There was good continuity of care, we had no issues.” One staff member told us, “Before the person moved in, we were told about their needs, and we were given their previous care plan. We were also given new training to meet the person’s needs.”

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on protecting people’s right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. Staff knew how to protect people from abuse and who they would report any concerns to both internally and externally. The service shared concerns quickly and appropriately. Deprivation of Liberty Safeguards (DoLS) were in place to legally authorise restrictions placed on people to keep them safe. The manager was reviewing people’s DoLS to ensure all restrictions were noted and considered.

The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them. There was an airway clearing device in the service for staff to use for choking emergencies. Comprehensive guidance, individualised to the home and people living there, was not available to support staff to use this equipment safely and appropriately. Following our inspection, the provider told us they had completed a comprehensive review of the use of this device in line with national guidelines and recommendations. The decision was made to decommission the use of this device across the provider group. We reviewed people’s care plans. We found some care plans lacked sufficient detail.

One person’s care plan, which stated their fluid intake was to be monitored due to them being at risk of urinary tract infections (UTI’S), did not state what the recommended fluid intake should be for this person, We reviewed recording fluid recording records for this person which were significantly below NHS guidance of 6 – 8 glasses (or cups) of fluid daily. This meant the person was at risk of becoming dehydrated. We spoke to the manager about this who took appropriate action to mitigate this risk. The manager shared examples with us of how the team were supporting a vulnerable person to maintain their independence by going out alone. They did this by educating the vulnerable person and by making contacts within the local community the person accessed so any concerns which arose could be raised and managed swiftly. One staff member shared with us an example of how they were supporting a person to maintain their independence within their home, which involved risk taking.

The service did not always promptly control potential risks in the care environment when they were detected. During our first on-site inspection visit, we observed a fire door was being wedged open. We spoke to the manager about this who told us the fire door was wedged open as the fire door release mechanism was broken and they wanted to make sure people could access the kitchen independently. The manager removed the wedge and contacted the landlord again about the broken mechanism. We noted in an internal audit conducted in October 2024, this fire door was noted to be wedged open. This meant people were at risk in the event of a fire. The service made sure equipment, facilities and technology supported the delivery of safe care. For example, firefighting equipment, gas, and electrical testing had been routinely carried out. Staff confirmed they received fire training. One staff member told us, “If there was the event of a fire you carry out an evacuation and ensure everyone is in a safe place.”

The service made sure there were enough qualified, skilled, and experienced staff to meet people’s needs. The provider’s recruitment policy described safe recruitment processes. We reviewed documentation for the most newly recruited staff which confirmed the provider was following their policy and recruiting staff safely. The provider did not always make sure staff received effective support, supervision, and development. We reviewed supervision records for staff and found these were not held as frequently as the provider’s policy stated. They also did not contain discussions around objective setting or personal development as per the provider’s policy. A staff member told us, “I have never had positive information about performance.” The staff team worked well together to provide safe care that met people’s individual needs. Staff told us, there were enough staff to allow them to provide consistent care and they felt the training programme equipped them with the skills and knowledge they needed to support people safely.

The service did not always assess or manage the risk of infection. They did not always control t he risk of it spreading or share concerns with appropriate agencies promptly. During our first on-site inspection visit, we observed the home had a strong malodour throughout and was unclean. We spoke to the manager about this, who told us, the malodour had been an ongoing issue, and they had been seeking support from the landlord. The manager told us, the unclean environment had been picked up in provider audits and a company had been organised to undertake a deep clean. The cleaners arrived later that day to commence a deep clean. We reviewed 4 weeks of cleaning rotas. Staff had signed to say they had completed the daily cleaning tasks, however, staff rarely signed the daily deep cleaning rota. Due to the lack of cleanliness in the home, we could not be assured these cleaning rota’s were always accurately completed, they also failed to drive improvement. We inspected the kitchen, we found multiple food items which had been stored incorrectly or did not have labels on dating when the item had been opened, meaning the disposal date could not be calculated. This meant people were at risk of being given unsafe foods. We spoke to the manager about this, who told us this had been picked up in audits and discussed with staff. The provider started to make improvements during our inspection. A senior manager told us, they would ensure spot checks were undertaken by their quality team to ensure good standards would be maintained.

The service made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. They involved people in planning, including when changes happened. Staff supported and involved people to manage their medicines and followed best practice for administering medicines. Staff and the manager were able to confidently tell us the process if a medicines error occurred. This included a debrief for staff discussing lessons learned and additional training.