Highview Lodge

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question Good. At this assessment the rating has changed to Requires Improvement.

This meant people’s needs were not always met.

The service was in breach of the legal regulation in relation to person-centred care. People’s care needs were not always fully identified and recorded.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always make sure people were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs. Not all care plans were person-centred.

Not all people using the service had a plan of care detailing all of their care and support needs and how this was to be delivered by staff. Not all care plans accurately reflected people’s current care needs. This meant there was a risk that relevant information was not captured for use by staff to demonstrate appropriate care was being provided and delivered in line with people’s support needs.

ABC records which help identify patterns, for example, triggers relating to how a person’s anxiety and distress presents, and what happens as a result, were poorly completed and did not provide sufficient evidence of staff’s interventions and outcomes.

Though meetings had been held with people about their personal preferences relating to social activities, people’s experience did not always evidence personalised care that met their specific needs. Not all people spoken with felt there were sufficient social activities available at Highview Lodge to meet their needs. A person told us, “Activities could be improved with things for ‘normal’ people and not just for those with dementia. I definitely feel I am losing my sanity here.” Another person stated, “They [Staff] take us on a walk occasionally.”

Observations on the first day of our assessment demonstrated there was a lack of social activities across the service, with an over reliance on the television. This significantly improved on the second day. As the weather was warm, people were supported to access the service’s garden. An intergenerational activity took place whereby children from a local nursery interacted and engaged with several people using the service. Meeting minutes from January 2025, recorded specialist events undertaken at the service, including the introduction of new external activities. For example, a celebration of the 80th anniversary of VE Day was undertaken in May 2025, where there was a wartime themed menu and an external entertainer. In March 2025 a walking group, the ‘Runwood Ramblers’ was created.

Following our feedback, the provider forwarded a Service Improvement Plan to the Care Quality Commission. This recorded a care plan tracker would be implemented and audits undertaken to help ensure care plans were followed consistently and to provide assurance information recorded would be robust and accurate. The provider told us additional training would be undertaken for staff. We will check on improvements the provider said they are making when we next visit the service.

The provider understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Staff worked with other services and involved people’s relatives to provide care and support to people. People received care from the same staff, so they experienced continuity of care as some staff had been employed at the service for some considerable time and agency staff had not been utilised at the service since February 2025.

The provider supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Care plans recorded people’s communication needs to guide staff on how best to communicate with the people they supported. The menu and activity programme were in an easy read and pictorial format to enable people with a disability and/or living with dementia to understand the information.

The provider made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support.

The peripatetic manager told us they encouraged people who used the service, relatives and staff to share feedback about the quality of the service provided, and what it was like to work at Highview Lodge. Quality assurance surveys had been forwarded to individuals, inviting them to provide feedback and suggestions for improvement. These were last completed in 2024. The surveys completed for relatives could not be located at the time of this assessment. The majority of responses recorded for people using the service were positive. However, where areas for improvement were cited, there was no action plan completed to indicate progress and if the actions raised had been addressed and completed.

The service had an open and transparent culture whereby people living at Highview Lodge and those acting on their behalf felt relatively confident about speaking up and raising any concerns. Comments from people using the service and relatives included, “I have not had to complain, it seems very nice here” and “Well, we would mention it [concerns] to the staff.” However, because of the lack of consistency of a day-to-day manager being available to oversee the service, people did not know who to approach from the senior management team. Comments included, “They need a permanent manager”, “I don’t know who the manager is” and “Who would I complain to, I don’t know.”

The provider made sure that people could access the care, support and treatment they needed when they needed it.

Discussions with people using the service and those acting on their behalf implied they had not experienced discrimination or inequality. Care records demonstrated people were able to access services, including a range of external healthcare services and professionals throughout the day, including out of normal hours and in an emergency. There was no evidence to suggest people experienced delays in healthcare provision.

Staff and leaders did not always actively listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this.

We identified shortfalls with the services care planning arrangements. Shortfalls in care planning can impact and create disparities in how people experience and benefit the quality of care provided. This was discussed with the senior management team as further improvements were required in this area.The management team were receptive to our findings, with some amendments to people’s care plan information immediately addressed.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Where people had an end of their life care plan in place, there was a lack of detail recorded relating to their decisions about their preferences for end-of-life care. For example, the information provided no specific evidence as to how they wished to be cared for so as to receive a comfortable, dignified and pain-free death. Following our feedback the provider forwarded a Service Improvement Plan to the Care Quality Commission. This told us arrangements would be put in place to ensure, going forward, people’s end of life care plans were more detailed. A revised end of life care plan was forwarded to the Care Quality Commission. This had been updated to reflect the person's end of life care needs and wishes.

Where appropriate, ‘Do Not Attempt Cardio-Pulmonary Resuscitation’ [DNACPR] orders were recorded. The service worked in partnership with other professionals, such as the local palliative care team to ensure people received appropriate end of life care. Staff had completed end of life care training.