Higher Park Lodge

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 Requires Improvement. At this assessment the rating has remained 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 provider was previously in breach of the legal regulations in relation to the staffing of the service, and the safe recruitment of staff. Improvements were found at this assessment and the provider was no longer in breach of these regulations.

The provider was previously in breach of the legal regulations in relation to premises and equipment, and the governance and oversight of the service. Not enough Improvements were not found at this assessment, and the provider remained in breach of these regulations. ​

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.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The service leaders were working to improve the culture of learning in the service but there were several areas where the service needed to improve. For example, Incidents and accidents were being recorded, but learning from these had not been recorded. As noted elsewhere in the report, care and support for people who had dementia needed to be developed, and the learning necessary for this to take place had not begun since our last assessment in June 2025.

An appropriate audit system was now in place. For example, the newly implemented IT based system for care delivery had a built-in audit system which identified when actions had not been carried out and identified these actions to the service management. However, the existing audit system had not led to a plan to address all the issues in the environment and with the facilities in the building.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The service had a safeguarding policy and procedure. Staff were receiving safeguarding training as part of their required mandatory training. Staff had raised issues to management where poor practice was witnessed. The service had significantly improved the quality of the service being provided and was no longer putting people at risk of harm.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service.

Everyone who showed symptoms of confusion and memory loss had been assessed for their capacity to consent to leaving the home without support. We found all those who used the service and did not have capacity to make informed choices, had a Deprivation of Liberty Safeguards (DoLS) application, or approved DoLS, in place.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People’s individual risk assessments were now up to date and accurate, recording changes to people’s risks and how these were being managed. Changes in a person’s risks were recorded effectively in either the person’s risk assessments or their care plan.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of good quality safe care.

When we visited the service there continued to be failures in the building’s environment, including furnishings, and equipment. The service was no longer cluttered, but there continued to be some damaged and inadequate furnishings in places, for example, all the lounge armchairs had worn out coverings, and blinds in the extension hallway were broken and so people could be seen, particularly at night, from the car park and adjacent park. The lower ground floor hallway carpet was worn through and heavily stained.

There was no longer a strong smell of urine throughout the home which had been present when we visited at our last assessment in June 2025. There was now an effective cleaning regime with an organised cleaning team in place, and they, together with the care and kitchen staff, were delivering a clean environment throughout the home.

Window openings on all windows above ground floor were now restricted in line with best practice guidance. Therefore, there was no longer a risk of a person falling from a height from the building.

Fire protection measures were now appropriately maintained to keep people safe. For example, self-closing fire doors had previously had holes from fitted lock mechanisms. These holes had been filled making the fire doors safe.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

There now was a staffing level assessment tool in use to identify the required level of staffing to meet people’s needs, and this was up to date with the dependency level for all those presently using the service. The availability of staff providing care and how they were organised was in line with the staffing level assessment tool, which meant there were adequate staff available to meet people’s needs.

Care staff completed adequate training. However, the list of mandatory training as required by the service, did not contain some training to give the staff further skills to meet some peoples’ needs. For example, the service was supporting a significant number of people who were living with dementia. Though some basic training for dementia care was available to staff this was not required by the service and was not in depth.

Staff received training in how to support someone who was nearing the end of their life. We were told a staff champion had been identified who would lead in this area of care and would work with staff to ensure end of life care was provided in line with best practice.

The service had not yet progressed the training on awareness of the needs of autistic people and people with a learning disability. All health and social care staff are required to undertake this training. The Induction training record was of poor quality but did show that the newest members of staff had received an Induction. We were told plans were in place to improve the quality of training as a whole.

The service policy was to hold individual supervision or appraisal meetings for all care staff every 6 months. We saw records showing that this was now taking place.

Staff were now being recruited safely. Records for the newest recruited staff showed that a DBS check had been carried out and all other required safety checks.

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.

When we last visited the service cleanliness was not being adequately managed. These problems had now been overcome, and the service was clean and did not smell of unpleasant odours. The domestic staffing was well organised now and there were no concerns raised about the cleanliness of either people’s rooms or communal areas.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.