Highams Lodge

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).