Highbury Rise

This assessment was carried out due to information we received about the service and due to the previous rating and breach. The assessment was unannounced and the provider’s first assessment under the single assessment framework.

At our last assessment we rated this service as requires improvement (published 07 September 2023) and found the provider was in breach of regulation in relation to safe care and treatment. Improvements were not found at this assessment, and the provider remained in breach of this regulation. In addition, at this assessment, we also found the provider in breach of the legal regulations relating to governance which included the submission of statutory notifications.

Medicine management systems were in place but not robust, this had been identified as an issue at the last assessment. The provider had implemented systems to address this however this required more consistency.

People required repositioning for pressure relief. We found this was not being done as needed. This placed people at risk of developing pressure ulcers. Following our feedback, the provider ‘positioning audit’ was reintroduced to help ensure better monitoring of people’s pressure care needs being met.

Recruitment processes were used to help ensure staff employed were safe to work in a care setting. However, staff files did not always include all the required information. This was identified as an issue at the previous assessment. Following our feedback, information was added to staff files. However, the oversight of this had not been robust.

The provider had systems in place to help ensure people received a good standard of care and that staff were supported and trained. However, these systems were not always used robustly. The systems had not identified the shortfalls we found as part of this system and had not fully and consistently, addressed the improvement points on the action plan from the last assessment. There were further systems being implemented to improve people’s lives and experiences.

Staff knew how to recognise and report any concerns relating to abuse. Information was displayed and safeguarding concerns were discussed with the local authority. However, notifications were not always sent to the Care Quality Commission (CQC) as required.

Infection prevention control was practiced. However, some areas of cleanliness, such as woodwork, could be improved.

The management team spent time around the home providing support and guidance. People, relatives and staff were positive about their presence, guidance and approach.

People, relatives and staff had opportunities for meetings and sharing their views. People’s choices were sought, and they were supported in accordance with their wishes and needs. Relatives were involved with people’s care planning and reviews.

Mealtime experiences were pleasant, staff checked on people to help ensure people ate well and enjoyed their food. People felt they had enough to do, and they had appropriate access to support services. People were supported by staff who knew them well. They had good relationships with each other.

There were enough staff to meet people’s needs. People and relatives told us staff were available when needed and they were kind, caring and helpful. Staff were positive about the service they provided, the management team and liked working there.

We have asked the provider for an action plan in response to the concerns found at this assessment.