A CARE home in Wem has been rated ‘inadequate’ following a surprise visit by Care Quality Commission inspectors.

Inspectors criticised staffing numbers, safeguarding, and medication protocols following their visit to Highbury House in Wem.

The inspection was unannounced, and it was done following multiple concerns highlighted at the last visit.


In their report, the officers underlined that The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves.

The inspectors said: “People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA.

“In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS).

“At this inspection we found the provider had not been monitoring people's DoLS authorisations and several had been allowed to expire.”

The officers added that during the investigation the current management team “could not locate the evidence” confirming the agreed restrictions have been considered under the MCA  and they were agreed in people’s best interests.

“Without seeing the documentation, we could not be reassured the principals of the MCA were being adopted and that all restrictions were lawful”, they added.

“Some people could require low level restraint during times of crisis, however, due to inaccuracies in care plans and the need for positive behaviour plans to be updated we could not be sure the least restrictive practice was being adopted.”

The governance systems in place continued to be ineffective, inspectors found, issues seen at the last inspection remained and further issues were identified as requiring attention.

Staff have also complained about being overworked and about agency staff that are constantly changing.

A member of staff talking to the inspectors said: "I do love my job, but I am exhausted.

“I never know who I am working with and whether people will be able to get out.”

Another worker added that they are “back to square one” since the agency supporting the home changed.

Inspectors noted: “There were insufficient numbers of suitably qualified and experienced staff being deployed to meet people's needs and mitigate any potential harm.”

The report also highlighted safeguarding concerns at the home.

The officers continued: “We could not be assured that people were protected from the risk of abuse or that lessons were learnt when things went wrong.

“Robust procedures were not in place to ensure concerns were identified and acted upon in a timely manner.

“Staff completed accident and incident forms when things went wrong, however, the provider had not yet reviewed all the completed forms.”

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Medicinal errors were also in the inspectors’ notes, and they found that the protocol was not very clear.

They concluded: “Guidance was in place to support staff to administer people's medicines.

“However, we found clarity was needed when people had different medicines for similar health needs.”

Highbury House of Achieve Together Limited have been contacted for a comment.