Highview Lodge

On this page

• 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

Well-led – 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 Requires Improvement. At this assessment the rating has remained Requires Improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of the legal regulation in relation to governance as the provider’s quality assurance arrangements were not effective.

This service scored 61 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Staff were able to demonstrate an understanding of the provider’s ethos and values.

Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

The service had had a lack of effective leadership to oversee the service since the previous manager left in October 2024. This lack of a consistent arrangement to have a suitably experienced and skilled manager in day-to-day charge of the service had adversely affected the consistency of service delivery including, the effectiveness of the provider’s governance arrangements. Senior managers brought in to manage and oversee the service had not routinely understood the challenges and the needs of the people being supported. We discussed this with the regional director and peripatetic manager who were overseeing the service at the time of our assessment. They acknowledged the service needed a suitably experienced manager in day-to-day charge of the service and confirmed a new manager had been appointed and was to commence in post on 19 May 2025. They told us the newly appointed manager would receive a robust induction and support from the peripatetic manager.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us, “I do feel confident to raise a concern, the management team are approachable” and “I am confident to speak to management if I had any concerns.” Staff had access to twenty-four hours a day, seven days a week, counselling and advice service. Regular anonymous staff surveys were conducted. Staff participated in team meetings and feedback forums, where staff could raise concerns or make suggestions.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There was a diverse workforce at the service, with staff employed from a wide range of backgrounds, cultures, and experiences.Staff told us they were treated fairly, felt supported and valued. The provider understood the importance of having a fair and inclusive workplace for all staff to work in. Staff received relevant training to inform their knowledge and understanding of equality, inclusivity and fairness in the workplace.

The provider did not have effective systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes.

The quality assurance and governance arrangements in place were not effective in identifying shortfalls found at the service as part of this assessment. We found that the provider’s systems to manage risks were not effective in that not all risks to people’s safety were identified and recorded. Care plans were not consistently accurate or recorded all of a person’s care and support needs. Not all care provided by staff for people using the service was person-centred. Improvements were required relating to staff supervision and ensuring where incidents had occurred there was effective learning and lessons learned.

Whilst senior manager reports prior to our assessment implied they were aware of the above, they had not taken enough action to address this and to mitigate the potential risks of people receiving inappropriate care.For example, provider compliance visits since October 2024, routinely recorded improvements were required to the service’s care planning arrangements, including the irregularity of care plan audits. Although action plans were completed, these failed to provide a clear audit trail of the provider’s progress to address the identified shortfalls. Senior managers had not recognised deficits in their governance and monitoring systems or taken effective actions to address these without us raising this at the time of our assessment.

We discussed these issues with the chief operating officer [South], regional director and peripatetic manager at the time of our assessment who acknowledged these failures. Following our feedback, the provider forwarded a Service Improvement Plan to the Care Quality Commission. The purpose of a Service Improvement Plan is to proactively identify and monitor performance, address weaknesses in service delivery and recognise areas for improvement. This confirmed the actions to be taken by the senior management team to address the shortfalls. The provider continues to provide an updated Service Improvement Plan to the Care Quality Commission mapping the provider’s progress.

Services that provide health and social care to people are required to inform the Care Quality Commission, (CQC), of important events that happen in the service. This enables us to check that appropriate action had been taken. The regional director and peripatetic manager understood their responsibilities to submit statutory notifications to the Care Quality Commission as required.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. The service did not always have a proactive culture of continuous learning and improvement. This was because the service had not had a registered manager in day-to-day charge of the service since October 2024 or a consistent senior management team to focus on continuous learning and improvement. The service was rated Requires Improvement at our previous assessment to the service in July 2024 and have not made all of the improvements required.