Highams Lodge

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety.

Systems to manage and review risk did not operate reliably. Risk information was not always updated or easily accessible, which meant staff relied on verbal handovers and records did not always reflect current risks. Safeguarding systems did not fully support effective oversight or tracking of actions.

Environmental safety controls, including those relating to fire risk and evacuation planning, were not consistently effective. Medicines systems did not provide robust oversight, with errors in controlled drug records, gaps in temperature recording and inconsistent escalation of concerns. Infection prevention and control systems lacked clear oversight, which reduced assurance that cleaning and hygiene standards were maintained over time.

Systems used to review safety, including incident reporting, safeguarding processes and management oversight, did not clearly show that risks were followed through or resolved. This reduced assurance that risks were effectively managed over time.

These shortfalls meant the provider could not demonstrate that risks were reliably identified, recorded and mitigated, resulting in a breach of Regulation 12 (Safe care and treatment).

However, across interviews, people described feeling safe most of the time and said staff were available around the clock to provide support. Staff responded when risks increased, including involving external services when required.

The service had safeguarding arrangements in place, and staff escalated concerns appropriately. The environment was generally homely and supported wellbeing and required safety checks were carried out. Staffing was stable, and staff received training and supervision to support safe care delivery. Medicines were stored securely and systems were in place to support administration.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The service did not consistently demonstrate that learning from incidents was followed through. Incident records were not always fully completed, and actions were not consistently tracked to completion. This limited the service’s ability to embed learning and reduce recurrence of risk.

Management reports and internal forums included information about incidents and service activity. However, they did not consistently show how learning was translated into clear actions or how improvements were reviewed. This limited assurance that learning was used to reduce risk.

However, people said staff were available when they felt distressed and responded when their needs changed. Staff accounts and records showed that staff acted when people’s mental health deteriorated, including increasing support and involving external services where required.

The service held regular handovers, supervision sessions and meetings which allowed staff and people to discuss care and safety. Staff described reviewing incidents and reflecting on practice as a team.

The service did not consistently demonstrate that systems used to manage risk across pathways were reliable. Daily records and information shared during handovers did not consistently result in updates to formal risk assessments or Keeping Safe Plans. While staff shared information verbally, this was not consistently reflected in formal documentation.

However, people described being able to come and go freely and said staff supported them to access community activities and maintain family contact, which supported their wellbeing.

The service had systems in place to support admissions, including referral screening and assessment prior to admission. Staff recorded daily information and shared updates through handovers. Staff had access to on-call management support, and records showed staff escalated concerns appropriately, including contacting external or emergency services when risks increased.

Records did not show that safeguarding systems supported effective oversight or follow‑through of actions. Records showed that safeguarding activity was recorded, but did not consistently include clear actions taken, outcomes or evidence of review. This reduced assurance that safeguarding risks were monitored over time.

Systems used to record safeguarding concerns, including management reports and internal tracking tools, focused on the number and type of concerns but did not consistently show progress or learning. This limited leaders’ ability to identify repeat patterns, themes or emerging risks across the service.

However, people described needing staff support at times when they felt unable to keep themselves safe, and staff responded to these needs. Staff escalated concerns to leaders and external agencies, including the local authority.

Safeguarding information showed that between April 2025 and February 2026 the service recorded 7 safeguarding incidents involving 5 people. These included overdose or self-neglect, threats to life or serious harm, a sexual safeguarding concern and fire-related behaviour. Emergency services were involved in 5 incidents, which showed staff acted when risks increased.

The service had clear escalation routes to an in-house social worker and senior leaders, and staff used these pathways when safeguarding concerns arose.

Systems did not provide assurance that people were consistently supported to actively participate in managing risks, when their needs changed.

Care and treatment records were inconsistently structured across records, and information was not always clearly organised or easy to locate. This reduced clarity about how risk-related decisions were recorded and shared with people.

However, people described using coping strategies to manage their safety during challenging situations, such as seeking support from staff or moving to a safer space.

Staff described working with people to understand triggers, preferences and strategies to reduce risk. Care and treatment records showed that people were involved in discussions about risk and safety, which supported a person-centred approach.

Environmental risks were not always managed effectively. Fire safety risks, including smoking behaviours, were not consistently controlled. Fire safety officers recorded that during a recent fire inspection, a person was observed smoking in their bedroom, which was not in line with the service’s no‑smoking policy and presented a known risk.

The provider described repeated activation of the fire alarm linked to the use of burning items within bedrooms, which indicated ongoing fire risks within the environment. Although the Fire Risk Assessment set out expectations for managing fire-related behaviours, the service did not have a clear written procedure to guide staff on how to monitor, review and manage these risks in practice.

Records from a recent fire drill also showed that staff were unclear about their roles during alarm activation. Some staff left the building without supporting people to evacuate. This indicated that fire safety procedures were not consistently understood or followed in practice.

Evacuation planning was not consistently robust. A Personal Emergency Evacuation Plan (PEEP) reviewed for 1 person was not dated or signed, which meant it was unclear whether it was current or regularly reviewed. Records from a February 2026 fire drill showed there was a delay in evacuating this person. The records did not clearly demonstrate that the cause of the delay had been identified or addressed. This reduced assurance that people who required additional support could evacuate safely.

One person told us they had raised a maintenance concern about very hot water and a leaking shower several times before it was addressed. This showed that some environmental issues were not resolved promptly.

These issues meant the service could not demonstrate that environmental risks were consistently identified and managed, resulting in a breach of Regulation 12 (Safe care and treatment).

However, the service carried out fire safety checks, which showed that the fire detection and alarm system was working and defects were addressed. A Fire Risk Assessment completed in March 2026 rated overall risk to life as moderate and identified actions for improvement.

The service completed electrical safety checks, including portable appliance testing, and carried out fire drills, including a timed evacuation drill in February 2026 with follow‑up actions recorded. Staff described routine checks of the environment, including regular room checks and discussions about health and safety.

People described the environment as homely and valued access to shared spaces and the garden, which supported their comfort and wellbeing.

People described staffing as stable and consistent, including at weekends, which supported predictable access to support.

The service used a mix of permanent and resource staff to deliver 24-hour support. Recruitment files sampled for resource staff included 2 references, and checks were in place with reminders when a Disclosure and Barring Service (DBS) check approached expiry.

The service supported staff performance and development through monthly supervision covering wellbeing, risks, performance, training and continuing professional development. The service maintained yearly appraisals.

Staff completed training in fire safety, medicines management and controlled drugs, safeguarding (adults and children), infection prevention and control, and equality and diversity. Therapeutic staff accessed weekly clinical supervision facilitated by an appropriately accredited professional, which supported reflective practice.

Infection prevention and control systems did not operate reliably. The service did not use cleaning logs to demonstrate completion of cleaning tasks, and there was no clear system to check that routine cleaning responsibilities were carried out. However, during the inspection, the environment appeared generally clean and tidy, which indicated that cleaning was taking place in practice.

Records did not clearly evidence the frequency of fridge temperature monitoring, which reduced assurance that food was consistently stored safely.

Staff described routine cleaning; however, the service did not maintain records to demonstrate consistent completion or oversight.

Taken together, these issues meant the provider could not demonstrate that hygiene standards were maintained over time or that risks were effectively monitored and managed.

However, staff completed infection prevention and control training as part of their mandatory training programme, which supported awareness of hygiene requirements and infection risk reduction. The service achieved a 5-star food hygiene rating in February 2026, and staff described daily kitchen cleaning and weekly cleaning groups involving people, reflecting a shared approach to maintaining cleanliness.

Medicines governance did not protect people from avoidable harm, and the service could not demonstrate effective oversight of key medicines risks. We identified concerns in three key areas: controlled drug governance, storage and monitoring, and escalation of clinical risks.

Controlled drug stock balances were incorrect for 2 of the 3 medicines reviewed, and the controlled drug register contained crossed‑out entries. The index page was not used, which made it difficult to locate entries and track discrepancies, increasing the risk that errors or diversion would not be identified or investigated promptly.

Temperature monitoring was not carried out reliably. There was a 5‑month gap in temperature logs, and there was no evidence of action when medicine cupboard temperatures exceeded manufacturers’ recommendations. This meant medicines may have been stored outside safe conditions, potentially affecting their effectiveness and safety.

Annual competency assessments for staff administering medicines were not always completed, and self‑administration risk assessments were not always reviewed in a timely way. Allergy information was incomplete in some records, which increased the risk of medicines being administered unsafely or without full awareness of individual risks.

Medicines supplied when people were on leave from the service were not always provided as prescribed, and some paper records were incomplete. Records did not show escalation when a person refused anti‑seizure medicine for several days or when a person’s blood glucose was outside expected ranges, increasing the risk of clinical deterioration not being recognised or acted on in a timely way.

Medicines audits did not identify the concerns found during the inspection, including controlled drug discrepancies. Where audits had identified issues, there was no clear evidence that actions were effective in preventing recurrence. Oversight relied on a single staff member, which limited independent scrutiny and reduced assurance that risks were identified and managed proactively.

These shortfalls resulted in a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

However, people said staff managed medicines more closely when there was a risk of overdose, including holding medicines to reduce immediate risk. Medicines were stored securely in locked cupboards.

Self‑administration risk assessments were in place and were generally detailed, and allergy status was recorded in some cases. Staff who administered medicines had received training, and staff described a culture of sharing learning following incidents.

The service worked with a community pharmacy and general practitioners to support clinical queries and continuity. Processes were in place for depot and blood monitoring to support attendance at appointments, and medication waste was separated and signed out appropriately.