CQC report explained · a residential care home
What the CQC found at Highbray Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured about most infection prevention measures, including testing, admissions, cleaning, hygiene and outbreak management. They were only somewhat assured that the infection control policy was up to date and that PPE was always used effectively and safely.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Good
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, April 2021
Highbray Residential Care Home: Inspected but not rated; inspectors found strong infection controls but gaps in written policy and mask risk planning.
This was an announced, targeted inspection on 1 March 2021. It looked at infection prevention and control during the coronavirus pandemic, rather than the full range of care provided.
Inspectors were assured about visitors, social distancing, admissions, testing, cleaning, hygiene and managing possible outbreaks. People kept in touch with relatives by phone and video calls, and were supported to socialise safely.
The home did not have a written infection prevention and control policy or contingency plan. Staff did not wear a mask when supporting one person because this caused significant distress. The manager completed a risk assessment about this after the inspection.
The service was inspected but not rated. This means the report does not give a Good, Requires Improvement or Inadequate rating for the home.
Testing and vaccination
The home had regular testing arrangements, and everyone living and working there had received a first Covid-19 vaccination at the time of the inspection.
“All people and staff had received their first Covid 19 vaccination.” from the report
Visitor safety
The home used signs, hand gel and PPE to reduce the infection risk from visitors and to limit their movement around the home.
“Procedures were in place to ensure the risk of any visitors to the service introducing infection were minimised.” from the report
Keeping people connected
People were supported to stay in touch with families and to socialise with each other during lockdown. The home also planned safe community trips and outdoor activities.
“Visiting was due to be reintroduced in line with government guidance on 8 March 2021.” from the report
Cleaning arrangements
The manager had a detailed cleaning schedule covering frequently touched areas, shared facilities and garden equipment.
“The registered manager had a robust cleaning schedule.” from the report
No written infection control policy
needs fixingThere was no written infection prevention and control policy or contingency plan. Inspectors signposted the provider to resources to develop these documents.
“There was no infection prevention and control policy in place.” from the report
Mask risk assessment
needs fixingStaff did not wear a mask when supporting one person because it caused significant distress. A risk assessment was completed after the inspection, so families should ask to see how this is now managed.
“Staff did not wear a mask when supporting one person because it caused them significant distress.” from the report
- 01Has the written infection prevention and control policy now been completed, and what does it cover?
- 02What is the contingency plan if the registered manager cannot continue providing care?
- 03What does the risk assessment say about supporting the person who becomes distressed when staff wear masks?
- 04How are visitors currently managed, including masks, hand gel and movement around the home?
- 05How are people currently supported to go out into the community and keep in touch with their families?
This was a targeted inspection of infection prevention and control measures during the coronavirus pandemic, not a full inspection of all five key questions. This explanation was written from the published report of 8 April 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, December 2018
Rated Good; inspectors found safe, kind and personalised care, with some records and quality checks still needing improvement.
This was an unannounced inspection on 5 and 6 November 2018. One inspector met all three people living at the home, spoke with the provider, manager, an advocate, a relative and a visiting professional, and reviewed care, medicines and quality records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found trained staff, safe medicines systems, personalised care plans, support with health needs, and respectful care that promoted people's choices and independence.
The overall Good rating stayed the same as at the previous inspection. The Well-led rating improved from Requires Improvement in April 2016 to Good, although inspectors said some quality monitoring paperwork was unnecessary and should be simplified.
Personalised support
Staff knew people's histories, preferences and communication needs well. Care plans gave detailed guidance about how each person wanted to be supported.
“The registered manager had detailed knowledge of each persons likes and dislikes, and bought them Christmas or birthday presents according to their individual tastes” from the report
Kind and respectful care
People were treated with patience, dignity and respect. Staff asked for consent, knocked before entering rooms and supported people to make choices.
“Staff told us, and we observed, that they treated people with dignity and respect.” from the report
Support with health needs
The home monitored people's health and worked with specialist professionals. Staff arranged healthcare appointments and provided extra training when people's needs changed.
“The service had worked effectively with relevant healthcare specialists, such as the speech and language team (SALT) and older people's mental health team” from the report
Safe medicines systems
Medicines were locked away, administration records were signed, and guidance was available for medicines taken when needed. Medicines audits and pharmacist reviews were in place.
“Medicines were kept in a locked cupboard and medicine administration records (MAR), were signed when medicines were administered.” from the report
Improved leadership
The Well-led rating improved from Requires Improvement at the 2016 inspection to Good. The manager was open about mistakes and acted on issues raised during this inspection.
“When we inspected in April 2016, the service was rated 'Requires Improvement' in this key area” from the report
One risk assessment was incomplete
needs fixingA person who was new to the home did not yet have a written risk assessment. The manager had identified the risks and was working on a formal assessment and care plan.
“One person, new to the service, did not yet have a written risk assessment in place.” from the report
Care plans were not formally reviewed as planned
needs fixingThe home aimed to review care plans monthly, but some had not been formally reviewed for some time. The manager planned to move to three-monthly reviews unless needs changed.
“The service aimed to review the care plans monthly, but they had not been formally reviewed for some time.” from the report
Quality paperwork was not well matched
minorQuality monitoring had improved, but some audit forms came from a different type of service and were unnecessary. The manager agreed to make the process simpler and more relevant.
“Much of the audit paperwork was unnecessary because it had been adopted from a different kind of service” from the report
Legionella assessment needed updating
minorA formal legionella risk assessment had not been carried out for some time. The manager arranged this before the inspection ended.
“A formal legionella risk assessment had not been carried out for some time.” from the report
- 01Has the written risk assessment for the newer resident now been completed, and how are risks managed when someone goes out into the community?
- 02How often are care plans now formally reviewed, and how are changes in people's needs recorded?
- 03What changes have been made to simplify and improve the quality monitoring paperwork?
- 04Has the legionella risk assessment been completed, and how often is it now reviewed?
- 05How is the home preparing to support the proposed expansion to include people living with dementia?
This was an unannounced inspection of the overall service covering all five CQC questions, based on visits, discussions and reviews of care, medicines and management records. This explanation was written from the published report of 4 December 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Highbray Residential Care Home
2 rated inspections over 3 years: the service has held its Good rating throughout.
- April 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
Read what inspectors found at Highbray Residential Care Home →
- December 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Highbray Residential Care Home →
- May 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- April 2011
Registered with the Care Quality Commission on 7 April 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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