Highgate Lodge Care Home

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

Safe – 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. There was an increased risk that people could be harmed. The service was in breach of legal regulation in relation to obtaining consent.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Effective systems were not in place to ensure lessons were consistently learnt to continually identify and embed good practice. For example, the systems in place to check the safety of medicines management were not always effective. This resulted in safety concerns not being consistently identified and acted upon to ensure lessons were learnt and improvements made. However, the providers systems to review accidents and incidents were effective. We saw this included a tracker for accidents and incidents which recorded the time, location, individuals involved, actions taken by staff, and any follow-up updates. Where incidents such as falls occurred, care plans were promptly reviewed and updated to reflect new risks and mitigation strategies. The registered manager told us they worked collaboratively with the person and their representatives and external agencies to promote a positive safety culture. For example, when a person experienced falls due to mobilising without support, the service involved occupational therapy, implemented a chair sensor mat, and submitted a Deprivation of Liberty Safeguards application. We saw these actions significantly reduced the risk of further incidents from occurring. Staff told us safety information was shared with them at handovers and at staff meetings. Relatives also told us they were kept up to date with regards to safety incidents that related to their loved ones.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. The provider had systems in place to assess people’s needs and develop care plans. Partners told us the registered manager completed assessments to establish whether the placement was appropriate for the person they were supporting. Care records we reviewed confirmed this as all care records contained preadmission assessments to identify people’s needs. Risk assessments were in place and regularly reviewed. External professionals, such as district nurses, were involved in supporting clinical needs, including monitoring blood sugar levels. The registered manager told us that case management teams also contributed to the ongoing review and coordination of care. People and their relatives told us that they were kept up to date with any changes to care plans.

The provider did not always ensure people’s rights were protected. For example, the use of CCTV for monitoring people. The provider had introduced CCTV to monitor people. We found there was no signage to inform people they were under continuous monitoring, and the provider was unaware that they required people to provide their consent to the use of CCTV. This meant people’s rights were not fully considered. The registered manager told us they would discuss this with the provider and address the issue identified. Where the registered manager and provider were aware that people were being deprived of their liberty, applications had been sent to the authorising body and these were referenced in people’s care plans. We also saw a Deprivation of Liberty Safeguards (DoLS) tracker in place. The applications however, had not fully considered the use of CCTV. However, people told us they felt safe at the home. One person told us, “I feel safe as there is always someone checking that I am alright” and “They would do almost everything for me, so I feel safe.” Relatives told us that they felt their family members were safe at Highgate Lodge. One relative stated, “100% safe. If anything worries me I would get in touch with people in charge there.” Staff understood how to recognise signs of abuse and knew how to report any concerns. We saw there was a safeguarding tracker in place. Safeguarding incidents were recognised and referred to the relevant safeguarding teams.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs in a safe, supportive way and enabled people to do the things that mattered to them. Risk assessments were in place and reviewed monthly. We saw risk assessments such as nutrition, hydration, Personal Emergency Evacuation Plans(PEEPs) and diabetes management. Staff had access to a diabetes management plan which provided guidance for them on what symptoms to monitor and what actions to take in the event of a medical emergency. People told us they were supported to maintain their safety, 1 person told us, “The surroundings and help are on hand, so I feel safe here.” Relatives told us they felt people were safe and the appropriate equipment was used to keep people safe. Where people were at risk of falls, the provider had requested additional support from medical professionals where appropriate.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. During our observations we identified an exposed pipe in the hallway, this was hot to touch and meant people were at risk of harm from burns and scalds. We also saw windows without restrictors in place putting people at risk of falls. Following our visit, the registered manager told us they had addressed the exposed pipe and fitted missing window restrictors. We will check this at our next assessment. We saw that some concerns raised in the fire safety checks from January 2025 had not been addressed. The registered manager showed us that they had been making progress with this, but this showed timely action to address the fire safety concerns had not been taken. However, we saw Personal Emergency Evacuation Plans (PEEPs) were in place for people which included information about how each person should be supported to evacuate the building in an emergency. People told us they felt safe within their environment. One person told us, “I feel safe enough there is lots of people around.” Relatives told us, “The home is very clean and well maintained.”

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. The registered manager told us they used a dependency tool that worked out how many staff they needed to support people based on their individual needs. We saw this had been effective in ensuring there were enough staff to support people. We saw staff were prompt and responsive in meeting people’s needs. For example, we saw a person became distressed due to the noise in the communal area, staff were available and supported and reassured them immediately. People, their relatives and staff told us they felt there were enough staff to keep them safe. One person told us, “I think that there is enough staff, they cope very well” and “There is always staff around.” However, some people were unsure if there were enough staff. One person told us, “They pack lots of us in here and don’t have the staff.” One relative told us, “If people need anything there is always someone there ready to help them. They have assistance to go to the toilet. They are all very nice. Nice young ladies”. Another relative told us, “On the whole staff do respond promptly whenever they can.” The registered manager told us there was a training matrix in place which gave them oversight of the training staff had undertaken and when this was next due. Records showed no gaps in mandatory training and evidenced staff had received training in a variety of topics, including; safeguarding, medicines administration and infection prevention control. We saw staff were recruited safely. This included checking their identity, their eligibility to work in the UK, obtaining at least 2 references and Disclosure and Barring Service (DBS) checks. We saw staff had regular supervision and annual appraisals.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The provider had a policy in place for Infection prevention Control (IPC). We saw IPC audits were completed monthly. The provider’s training matrix showed staff had received IPC training and we saw staff used the Personal Protective Equipment (PPE) available. One person told us, “The place is always clean and tidy.” Relatives also confirmed the environment was clean and well maintained.

The provider’s medicines systems did not consistently ensure the safe administration of medicines. The number of medicines on site did not match the number recorded on the provider’s records which meant we could not be assured people had received their medicines as prescribed. The Deputy Manager could not account for these inaccuracies and told us that they would complete an investigation to identify the cause. Where people had ‘as required’ medicines, there was no guidance in place to ensure these were administered in line with how they were prescribed. This meant we could not be sure people were receiving their medicines as prescribed. We were told by the registered manager that they were in the process of putting ‘as required’ protocols in place. We will check these at our next assessment. Regular audits of medicines management were carried out by managers, however these audits had not identified the medicines concerns we have referenced in this report. However, people told us they were happy with how they received their medicines. One person said, “They never forget to give me my medication.” There were no gaps in medicines records and where people had missed medications there were recorded explanations for this. Where people had a plan in place for covert medication we saw this was in line with the legal requirements and there was guidance from a GP documented.