Highams Lodge

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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

This means we looked for evidence that service leadership, management and governance assured high‑quality, person‑centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high‑quality, person‑centred care.

Governance systems did not provide effective oversight. Key information was not consistently recorded or accessible, and records were incomplete or inconsistent across the service. Incident processes were not always completed or reviewed, and systems did not clearly demonstrate analysis, learning or action. Leaders could not consistently demonstrate that risks were effectively monitored and followed through, which reduced assurance that the service improved over time.

Although formal processes were available for staff to raise concerns, confidence in speaking up was reduced where issues were not acted on in a timely way. This limited opportunities for learning and improvement.

Partnership working was not consistently developed or embedded, and the service could not demonstrate established links with wider community resources to support progression and integration. There was limited evidence that equality, diversity and inclusion needs were consistently identified and recorded within care processes.

However, leaders promoted a relational and reflective culture aligned with the service’s therapeutic model. People and staff described leaders as visible and approachable, and staff described open communication within teams. Leadership structures were in place, including supervision, meetings and reporting processes intended to support oversight and service development.

These governance and oversight gaps meant the provider could not demonstrate effective systems to assess, monitor and improve the quality and safety of the service, resulting in a breach of Regulation 17 (Good governance).

We have not awarded this service a score for Well-led.

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

People described a strong sense of community, which supported engagement in day‑to‑day life in the service. Leadership described a relational and reflective culture to support the service’s therapeutic approach.

The staff handbook set out values relating to boundaries, working with others and the therapeutic community ethos. Leadership meetings took place quarterly to support service development, and staff described shared thinking within the team.

People said they felt able to approach leaders during meetings. People commented that leaders were visible and supportive during incidents.

Leaders participated in community forums with people, and a senior leader agreed a budget for a garden project during a community meeting. We also observed the same senior leader attend a budget meeting, where they engaged directly with people and contributed to discussions.

Staff said they could discuss challenges openly.

However, some staff said leaders did not always consider their professional views and sometimes needed to be assertive to have these heard. Staff feedback about responsiveness was mixed. These suggested staff views were not always fully reflected.

Although there were formal systems in place for staff to raise concerns about any elements of care, staff said previous concerns raised had not always been acted on in a timely way. This reduced confidence that speaking up would lead to change. Not all senior leaders could describe the formal processes for raising concerns.

Despite this, the service did have formal routes for staff to speak up when they had concerns. There was a whistleblowing policy in place and specific senior leaders within the organisation were responsible for receiving concerns. This information was made available to staff during their induction and in a staff handbook. Staff also described opportunities for raising concerns through supervision and day‑to‑day discussions with colleagues and working relationships within teams supported open communication.

The service did not consistently demonstrate how equality, diversity and inclusion were embedded within workforce practice. While staff completed annual equality and diversity training, there was limited evidence of how this was reinforced through supervision, team development or day‑to‑day practice. This reduced assurance that equality, diversity and inclusion principles were actively applied by staff when delivering care.

The provider had set out equality, diversity and inclusion values in written guidance; however, these were not consistently reflected in how staff applied or translated these into practice. This indicated that training and organisational values had not fully embedded into consistent workforce behaviours.

At the time of our inspection, governance systems did not provide effective assurance. Leaders could not confirm staff had read or understood the business continuity plan and the service did not have a system in place to check staff awareness. This meant the provider could not demonstrate that continuity arrangements would operate reliably in practice during disruption.

Governance information about risk, safety, safeguarding, feedback and quality was held across multiple systems and formats. This made it difficult for leaders to maintain a clear line of sight across the service, identify emerging patterns in a timely way or track actions through to completion. Care and treatment records were organised differently for different people, with information held across both paper and electronic systems. This meant staff could not always locate key information quickly. At the time of the inspection, the service was part-way through a planned, staged migration to a fully electronic record system.

Evidence also showed missing or empty physical health information folders in 3 examples. Where information was not present, the service could not demonstrate whether actions had been completed or whether monitoring had taken place.

The service produced monthly management reports which included detailed information about occupancy, incidents, engagement, therapy attendance and move on activity. However, sections within these reports were incomplete or left blank across multiple areas, including safeguarding, training, incidents and move on planning. Although the most recent management report available at the time of the inspection was dated December 2025, we saw during the inspection that managers were using data that was more recent in their management meeting discussions.

Information recorded within the reports did not consistently include detail about actions taken following incidents or changes in people’s engagement. Sections relating to escalation and follow up were not always completed, and records did not show how issues identified within the reports were progressed or reviewed over time. This meant the service could not demonstrate that information was consistently used to inform decision making or action.

Not all incidents were completed or signed off. In January 2026, 3 incidents were awaiting completion, in February 2026 there were 4, and in March 2026 there were 4 incidents, including 3 not yet completed or signed off. This meant there was not always a clear record that incidents had been reviewed, and actions completed in a timely way or followed through to resolution.

Monthly management reports did not consistently demonstrate how incident information, safeguarding concerns or feedback were reviewed to identify patterns across the service. This limited leaders’ ability to use information to understand risk, identify themes or demonstrate learning and improvement.

Leaders collected data, but records did not show consistent review, decision making, action tracking or evaluation. As a result, they could not demonstrate that governance systems operated effectively to assess, monitor and improve the quality and safety of the service.

These gaps meant the provider could not demonstrate effective processes to assess, monitor and improve the quality and safety of the service, resulting in a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

However, governance structures included a risk register, supervision arrangements and internal audit processes. These identified risks within the service, including self‑harm, placement breakdown and staffing pressures.

The service did not consistently evidence proactive partnership working beyond immediate clinical and risk-related needs. Care and treatment records did not routinely demonstrate ongoing engagement with external professionals or how information shared between services informed care planning. This meant there was not always a clear record of how external input contributed to people’s care.

Records showed limited evidence of how wider community resources, education and employment opportunities were used to support recovery and progression. Whilst people participated in community activities, records did not consistently demonstrate structured links that supported longer-term progression and integration. This limited assurance that people were consistently supported to build meaningful connections, develop vocational or educational opportunities and prepare for life beyond the service.

However, the service worked with external professionals when people’s needs increased. Staff described liaising with community mental health teams, general practitioners and emergency services, and records included examples where external support had been accessed in response to risk. Care and treatment records also contained some evidence of communication with professionals involved in people’s care, including updates following incidents or changes in need.

The service did not consistently demonstrate that learning led to improvements in practice. Information about incidents, safeguarding, engagement and activity was recorded; however, records did not show how themes were identified or used to inform changes across the service. This limited the service’s ability to demonstrate sustained improvement.

There was no clear evidence of structured improvement planning. Records did not demonstrate defined objectives or how actions were reviewed over time, which limited oversight of whether changes led to improvement.

Approaches to improvement were not consistently planned or monitored in a structured, service‑wide way, and relied more on informal practice. This reduced consistency in how learning was applied.

However, the service supported reflective discussion through supervision and team forums, where staff could reflect on their practice and share learning.