Hightown Road

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 service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 61 (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 shared vision, strategy, and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The manager told us, “We ensure we give people the best lives possible, right care, right culture, right support. As an organisation we have forums where updates from CQC, best practice, policies or changes to audits are shared. We have a new strategy wheel which is about making sure people get their preferences met. We have voice groups for people.” The manager also told us how they monitor and assess the culture of the home to ensure a closed culture does not develop.

The service had inclusive leaders at all levels who understood the context in which they delivered care and treatment. Leaders did not always have the skills to lead effectively. We reviewed 3 team meetings, dated between August 2024 and January 2025, these meetings all detailed the concerns with the unclean environment, incorrectly stored and unlabelled foods. These team meeting’s had failed to drive improvement. All staff spoken to, told us the manager was not visible on a daily basis. They did tell us they could contact the manager via the telephone when needed. We spoke to the manager about this, who told us, they would now be working in the home 3 days a week, and another member of the management team would be working on the days they were not in the home to ensure there was a management presence within the home. The manager told us they were supported by the provider’s management team who were available to them when needed. Staff had access to training to help them develop further in their roles and the manager told us in detail about the opportunities for staff progression within the organisation.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Staff members told us the manager had an open door policy and there were equal opportunities for all. People living in the home were asked for their views in a variety of formats. We reviewed people’s daily notes which evidenced their choices, input, and involvement throughout their days. We reviewed evidence of people being supported to develop new skills. People’s support was regularly reviewed, and their families were involved in this process. The provider also sent out satisfaction surveys. Action plans were devised from these meetings and survey’s and were shared with people. This meant people’s views were listened to and drove improvement.

The service 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 felt supported to give feedback and were treated equally, free from bullying or harassment. We reviewed evidence of multiple webinars held by the provider throughout the year on a range of topics which included Equality & Diversity, LGBTQIA+ and Mental Health, these were available to the people who were being supported as well as the staff team.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance, and outcomes. We reviewed provider audits which dated back to July 2024 which continuously detailed the same concerns we found during our February 2025 inspection with the malodour, unclean environment, incorrectly stored and unlabelled foods. We reviewed provider audits which detailed staff supervisions and team meetings were not being held in line with the provider’s policy. The provider audits failed to identify guidance relating to the airway clearing device was not sufficiently comprehensive. Therefore, the provider’s audits failed to drive improvement. We spoke to a senior manager about this who told us, they have set out clear expectations of their staff and they will use their formal performance policy to ensure compliance moving forward. They told us they will monitor this by ensuring their quality compliance team carry out spot checks of the home. Following the inspection the provider told us spot checks were everyone’s responsibility, and the senior manager would ensure spot checks were undertaken. The manager was able to confidently tell us how they ensured safe record keeping by following the principles of General Data Protection Regulation (GDPR).

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborate for improvement. Relatives, staff, and the manager shared with us positive examples of collaborative working in partnership. One professional told us, “The telephone call with the carer was appropriate with relevant information given.”

The service 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. The provider was slow in making improvements to the environment as we have previously mentioned in other areas of this report. When asked, the manager was unable to provide us with any examples of innovation, they told us, “My priority is making sure the home is in a good place and making sure the people are safe and that we keep to those standards and don’t go back to how it was before I started.” We did find the provider was responsive throughout the inspection process and did tell us what they have put in place to improve outcomes for people.