Highbury House Mental Health Unit

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• 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

Records required more detail to ensure they were person centred and contained all the required information. Action plans were in place and updated to address this. However, systems were in place which were used to drive improvement. Various audits were undertaken both at location and provider level to monitor the quality of the service provided and to maintain oversight.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff told us they felt supported and listened to by the registered manager and the management team. Staff felt involved in the running of the service and were able to share any ideas, or concerns in meetings, supervisions, or when the need arose. Staff felt valued. A staff member told us, “We all work well as a team. I think the service is managed in people’s best interests and people receive a good standard of care. We receive good leadership and direction, and the management team are really supportive in all that we do.” The registered manager felt supported by the provider. Operation managers visited the service on a regular basis to maintain oversight and support to the management team. Regular managers meetings were held to share updates and learning.

We found some records did not always contain sufficient detail of events for example, when restrictive practices were used. The provider had identified additional training was required in this area and further training was being arranged. Daily records were not always detailed and did not always relate to people’s mental health and associated risks for ongoing monitoring. Fluid monitoring was not always robust to ensure low intake was monitored and escalated. Some people’s medicines records were either not in place or had not been updated to ensure staff had access to the required guidance to support with people’s medical needs. Some potential risks to people had also not always been considered. The homes action plan was updated in response to our feedback to address the areas we had raised. Systems were in place to monitor the quality of the service. Audits were completed on a local level by the management team and by the operation managers who visited the service on a regular basis. Ongoing actions plans were in place to address shortfalls from audits that were completed and in response to learning from the providers other services. Staff understood their roles and responsibilities and there were clear lines of delegation. The registered manager was aware of the need to promptly inform CQC of any notifiable incidents in accordance with their legal responsibilities.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.