Highams Lodge

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.