Highfields Nursing Home

Highfields Way, Blackwood, NP12 1SL
No of beds: 39 Care Home with Nursing
Category: 28 Older Person (Nursing) / 10 Older Person (Residential) / 1 Physical Disability
Dual Registered
Tel: 01495 225221
Email: mrkhan.highfields@yahoo.co.uk
Website: www.highfieldscarehomewales.co.uk

Contract Monitoring Report

  • Name/Address of Provider: Highfields Nursing Home, Highfields Way, Blackwood,
    NP12 1SL
  • Date of Visit: Wednesday 10th May & Thursday 15th June 2023
  • Visiting Officers: Ceri Williams, Contract Monitoring Officer
  • Present: Shawkat Ilahi, Registered Manager


Highfields is registered to provide residential and nursing care for up to 39 people. The home is a two-storey building, all rooms are single occupancy.

At the time of the visit the home has 31 residents: 20 receiving nursing care 11 receiving residential care.

Dependant on the findings within the report, corrective and developmental actions may be given to the provider to complete. Corrective actions are those which must be completed as governed by regulations such as the Regulation & Inspection of Social Care (Wales) Act 2016 (RISCA). Developmental actions are good practice recommendations.

Previous Recommendations

Corrective Actions

All Regulation 60 notifications to CIW to be copied to the Commissioning Team (as per CCBC care home contract). Not met.


No developmental actions were found at the last visit.

Findings from Visit


Two residents’ care files were viewed at the visit. Both residents were receiving residential care at the home. Both files contained the appropriate preadmission assessments which was a thorough document regarding the care needs of the resident.

Personal Plans viewed on both files covered all areas of support identified in CCBC care plans, which were present on both files. Personal Plans were person-centred and contained in depth content on how to manage resident’s conditions and contained personal preferences and routines.

Personal plans viewed were also signed by the resident or their representative, evidencing that they had been involved in the production of the plans.

Suitable Risk Assessments were in place, where appropriate, to meet resident’s needs.

Both personal plans and risk assessments are reviewed on a monthly basis, which is good practice, and any changes are documented, and plans updated if required. Although personal plans are being reviewed, there was no evidence that reviews are undertaken involving the individual or, if appropriate, their representative.

There was evidence on the files seen that the residents’ health is monitored appropriately, with various referrals to health professionals such as GPs, dieticians, and dentists.

Each personal plan included individual goals and outcomes followed by a list of the support needed to help the resident achieve them. Both files contained agreements with family members/representatives about being informed about incidents, which had been signed by the residents. Both files also contained Advanced Care Plans for the residents and DNACPR’s on file which had also been discussed with family members.

Life History documents were present on both files and contained good detail regarding resident’s early years, interests, occupation and what was important to them.


Highfields employs a full-time activities co-ordinator and a programme of activities are planned weekly taking residents suggestions into account.  Events are advertised on a notice board and also in a newsletter for people who spend time in their rooms so they are aware of events should they wish to attend.  Residents recently celebrated the Kings coronation and an event was planned for the upcoming Eurovision Song Contest.  On the days of the monitoring visits residents were observed baking cakes and enjoying a ‘by the seaside’ theme day enjoying ice creams and paddling pools.

Facilities & Observations

The monitoring officer walked around the home during the day and all areas were seen to be clean and tidy. All bedrooms were individually decorated, and contained several personalised items such as ornaments, pictures etc.

The monitoring officer spoke to residents during the visit, and it was pleasing to hear positive comments about living at the home, including the friendliness of the staff, the food, and the activities on offer.

Staff were observed treating residents with dignity and respect at all times and, it was noted that residents were offered choice, regarding where they wanted to spend time during the day and lunch options. The activity planned for the day had also been changed in response to residents preferences.

The last fire assessment was seen.  There had been two recommendations which the Manager evidenced had all been completed. The maintenance file evidenced regular audits with regards to fire safety.

Personal Emergency Evacuation Plan’s were available for all residents and evidenced that people were assessed for their manual handling needs in case of emergency evacuation and differentiated between day and night time evacuations.  These plans are also reviewed on a monthly basis.

The home have recently received the annual Food Hygiene Inspection and have retained their 5 star rating.


Highfields uses a mixture of online and in-person training provided by the Local Health Board, CCBC and an external training provider. Staff are able to identify their own training needs during supervision sessions.

The training matrix provided, evidenced that all mandatory training is undertaken regularly, and that all staff are up to date. There was also evidence of a good range of non-mandatory training that staff had undertaken to enable them to fulfil the requirements of their role and meet the needs of the individual residents.


During the day the home is staffed by 6 carers, 2 Nurses, 1 Activities Co-ordinator, 2 Domestic Assistants and 2 Kitchen Assistants.  The home manager and administrator are also present Mon – Fri.  During the night the home is staffed by 4 Carers and 1 Nurse. 

Two staff files were viewed during the visit. The recruitment process was found to be robust.  Checklists are used to ensure all the required documents are in place prior to commencement. Both files contained the necessary information required. There was evidence ensuring that appropriate checks had been made as part of the application process, such as an application form, two references, and an interview record. Both files contained a signed contract of employment, and a job description, full employment history and evidence of identity. Both files contained evidence that a DBS check had been completed before the member of staff started work, and the Manager confirmed that these are completed every 3 years.

A Supervision Matrix was provided and evidenced that all staff receive Supervision within the timescales specified in regulations. Examples of Supervision were viewed.  Sessions and recordings of Supervision were detailed and included opportunity for staff to reflect on their practice and any other issues they wished to raise. Evidence was also seen of all staff having received an annual appraisal.  Records were detailed and included an action plan, career development and comments from both appraiser and appraisee.

Quality Assurance

A copy of the quality assurance report was provided.  There is clear evidence of involving residents, relatives, staff and other stakeholders in the quality assurance process. However, there was no evidence that the quality of care reviews are being undertaken every six months as required by regulations.

Also provided to the monitoring officer was the Responsible Individuals quarterly monitoring report to monitor the performance of the service. This was a comprehensive document and included resident feedback, staff feedback, Care planning and daily recordings, building maintenance and any accidents or incidents. The report resulting from the RI visits would benefit by being a separate report from each visit, instead of the combining of two visits into one report. This would make it easier to read and any actions resulting from the visit can be clearly identified.

Evidence was available of comprehensive monthly audits undertaken, information is obtained and acted upon for continued development and improvement. Heath & Safety meetings are held quarterly with management and senior members of staff.  Discussed in these meetings are incidents/accidents and any actions and learning documented. Audits, training and property maintenance are also discussed. 

Policies and procedures are available to staff via an app on their mobile phones, which also alerts staff when any policies or procedures have been updated or reviewed.

There is a handover led by a nurse before each shift starts, and this attended by all care staff and nursing staff. During the handover information and updates are shared about all residents, including any important changes and is also documented.

There is a comprehensive home maintenance manual which evidences any improvements and works to be carried out around the home.  Also included are daily, weekly, monthly, quarterly and six monthly checks, for various aspects of the environment of the home.

Feedback from residents spoken to during the visits was positive regarding the care and support provided and also the staff and the management of the home.  The manager is visible and approachable to both staff and residents throughout the home.

Relatives of two residents were also contacted for feedback. Both relatives confirmed that their family members had settled well into the home and they had no concerns regarding the care and support provided.  Both said that they felt welcomed into the home whilst visiting and while neither had any cause to raise any issues or concerns, they both stated that they felt that the staff and manager were approachable, and would feel comfortable doing so, if the need arose. They are, as families, kept informed regarding any changes in their relatives care and support and always advised of any hospital/medical appointments.  They described their loved ones as ‘very happy’ and ‘loves it there’ when asked about living at the home.

Corrective / Development Actions

Corrective Actions

Reviews are undertaken and, where appropriate, with the agreement of the individual, their representative at least every three months. (Regulation 16, Regulation & Inspection of Social Care (Wales) act 2016 (RISCA).

Quality of care and support to be reviewed at least every six months. (Regulation 80 RISCA)

Regulation 60 notification submitted to the regulator to be copied to CCBC Commissioning Team. (CCBC Contract)

Developmental Actions

RI Regulation 73 reports to be reflective of visits carried out by the RI and documented for each visit.


There was a warm and friendly atmosphere throughout the visits to the home.  Residents were observed being given choices by staff regarding their care and support needs, how they wanted to spend their day and meals/snacks. 

Documentation was of an excellent standard and everything that was requested by the monitoring officer was promptly provided. The contract monitoring officer would like to that the residents and staff for their time and hospitality during the visit.

  • Author: Ceri Williams
  • Designation: Contract Monitoring Officer
  • Date: 07 July 2023