CQC report explained · a nursing home
What the CQC found at Highbury Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, June 2023
Rated Requires Improvement; inspectors found important safety, training and management weaknesses, although the home had improved from Inadequate and left special measures.
This was an unannounced follow-up inspection carried out over four days in May 2023. Inspectors spoke with people, relatives, staff and a health professional. They reviewed care plans, medicines records, staff files and management records.
The home had improved since its previous inspection, including recruitment, medicines, fire safety, activities and monitoring of some health risks. People and relatives generally described staff as caring, and there were enough staff on duty.
However, incidents and possible safeguarding concerns were not always investigated or reported. Inspectors also found gaps in staff training, incomplete information about people's wishes, environmental repair issues and weak quality checks. The home was still in breach of four regulations.
All five areas were rated Requires Improvement. The home was no longer rated Inadequate overall and was no longer in special measures, but CQC said there was still limited assurance about safety and an increased risk that people could be harmed.
Improved recruitment
The home had introduced pre-employment checks, inductions and competency checks. Inspectors found enough staff and no recent use of agency staff.
“The provider had taken steps to significantly improve recruitment practices.” from the report
Safer medicines
Medicine instructions, staff checks and records had improved. The medicine administration records reviewed had no gaps.
“At this inspection we found significant improvements in how people were supported to take their medicines.” from the report
Better health-risk care
Staff knew about important risks such as choking, falls and wounds. Inspectors saw effective wound care and a pressure wound had fully healed.
“We saw 1 person who had had pressure wounds which had fully healed as a result of effective wound care.” from the report
More activities
The home had recruited extra staff to support activities and had asked people what they wanted to do. Most people spoken with enjoyed the activities and events.
“The provider had taken steps to recruit additional staff devoted to spending time with people and helping them engage in activities they enjoyed.” from the report
Safeguarding investigations
seriousSome injuries, incidents and possible abuse concerns were not properly recorded, investigated or referred to the local safeguarding team. This left people at risk of abuse or improper treatment.
“The provider had failed to notify the local authority's safeguarding team when concerns of the risk of possible abuse had been identified.” from the report
Unidentified safety risks
seriousChecks did not identify risks including unsecured stair access, unlocked storage cupboards, damaged surfaces and unsafe access to thickener. Some people also lacked clear guidance about how staff would keep them safe if they could not use a call bell.
“Systems to monitor people's health and safety were not always robust or effective.” from the report
Staff training gaps
seriousMany care staff had not received training needed for people's conditions and rights, including dementia, learning disabilities, diabetes, epilepsy, the Mental Capacity Act and DoLS.
“The provider had failed to ensure staff received all the training needed to support people effectively.” from the report
Care was not fully personalised
needs fixingCare plans often covered basic health needs but did not give enough detail about personal history, wishes, preferences, cultural needs or end-of-life choices. Some 'all about me' information was inaccurate.
“Care plans contained information about people's basic care needs but were not yet very personalised.” from the report
Weak management checks
seriousAudits and monitoring systems did not reliably identify problems found by inspectors. This included missed safeguarding concerns, incomplete investigations, repair problems and training gaps.
“The provider had established systems, but they had not always enabled the management team to effectively monitor and improve the safety and quality of people's care.” from the report
End-of-life planning
needs fixingNo one was receiving end-of-life care during the inspection, but staff had not received end-of-life training and people's wishes were not always recorded in enough detail.
“People's end of life wishes were not always detailed in their care plans.” from the report
- 01What action has been completed to ensure every incident, injury and possible safeguarding concern is recorded, investigated and referred when needed?
- 02Which staff have now completed training in dementia, learning disabilities, specific health conditions, the Mental Capacity Act and DoLS?
- 03How will you make sure my relative's care plan records their history, wishes, preferences, cultural needs and end-of-life choices accurately?
- 04What repairs and environmental changes have been completed, including damaged walls, the bathroom floor and storage cupboard security?
- 05How are you checking that the improvements reported monthly to CQC are lasting and that new risks are identified promptly?
This was an unannounced follow-up inspection covering all five key questions and infection prevention and control, following the previous Inadequate inspection. This explanation was written from the published report of 20 June 2023 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, February 2023
Highbury Nursing Home was rated Inadequate in every area and placed in special measures because inspectors found serious risks to people's safety and care.
This was an unannounced inspection over three days. Inspectors spoke with 17 people, 14 relatives and friends, and 11 staff. They reviewed care records, medicines records, recruitment files and management documents.
Inspectors found widespread problems. These included unsafe risk management, too few staff, gaps in medicines records, poor staff training, unsafe premises, unmet nutrition and hydration needs, and failures to follow the Mental Capacity Act. People were not always treated with dignity, and care plans did not give staff clear guidance.
The home was also not responsive or well-led. People did not have enough meaningful activities, complaints were not properly recorded or followed up, and quality checks had failed to identify serious problems. All five areas were rated Inadequate.
The report says this was the first inspection of the newly registered service. The previous provider's rating, published in January 2020, was Requires Improvement. The home was placed in special measures, meaning CQC would closely monitor it and normally reinspect within six months.
Involvement in decisions
The report says people and their relatives were involved in making some decisions about care, although other parts of the report say care reviews were not consistently recorded or carried out.
“People and their relatives were involved in making decisions about their care.” from the report
Advocacy information
Information about independent advocacy services was available to people and their families.
“The provider had made information available to people and their families about advocacy services that can provide independent support and advice.” from the report
Serious safety risks
seriousRisk assessments and care plans were incomplete. Inspectors found significant fire safety concerns and said an accident that caused injury had not led to effective action to prevent it happening again.
“We saw evidence of harm to people. Systems were either not in place or robust enough to demonstrate safety was effectively managed, this placed people at risk of further harm.” from the report
Staffing and training
seriousThere were not enough staff to meet people's needs, and many staff had not completed essential training or received supervision. Recruitment checks were also inconsistent.
“The provider had failed to ensure there were sufficient numbers of staff on duty to meet people's needs.” from the report
Medicines management
seriousMedicine administration records had gaps, instructions for creams and as-needed medicines were unclear, and staff had not had recent medicines training or competency checks.
“We found multiple gaps in several people's medication administration records (MAR). This meant the provider could not be assured people were receiving their prescribed medications as intended.” from the report
Nutrition and hydration
seriousPeople's diets were not always matched to their medical needs. The home did not always seek specialist advice when people were at risk of choking or losing weight.
“The failure to meet people's nutritional and hydration needs was a breach of Regulation 14 (Meeting nutritional and hydration needs) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Dignity and independence
seriousPeople were left in undignified situations and were not always supported to remain as independent as possible. Inspectors also found restrictive practices without clear reasons recorded.
“This meant people were left in undignified situations.” from the report
Weak management oversight
seriousThe home did not have effective audits or systems for learning from incidents. Staff said they felt unsupported, and there was no registered manager in post at the inspection.
“The provider failed to ensure effective systems and processes were in place to assess, monitor and improve the safety and quality of people's care.” from the report
- 01How many permanent nursing and care staff are now working on each shift, and how are staffing levels checked against people's needs?
- 02What action has been taken to correct the fire safety concerns and complete testing of fire and electrical equipment?
- 03How are medicines records, staff medicines competency checks and as-needed medicine instructions now audited?
- 04How are people's care plans and risk assessments reviewed when their health, mobility, nutrition or communication needs change?
- 05What evidence can you show of progress against the monthly improvement reports, including safeguarding, Mental Capacity Act and complaints actions?
This was an unannounced full inspection of the care home, including both the premises and the care provided, and all five key questions were assessed. This explanation was written from the published report of 22 February 2023 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 Highbury Nursing Home
5 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- June 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2023InadequateSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- February 2022Inspected but not ratedSafe: Inspected but not rated
- January 2020Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2017Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2021
Registered with the Care Quality Commission on 9 December 2021.
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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