Highborder 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.

This is the first assessment for this service. This key question has been rated 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 people’s safe care and treatment.

This service scored 50 (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. The provider was working hard to change the learning culture at the service, supporting staff to identify where things went wrong and embed good practice. However, this needed more time to fully embed into the service.

We found some staff shortfalls in the identification of safeguarding concerns for people, in relation to falls and medicines management. The provider was working to improve staff knowledge and skill set to better support staff. The provider told us, “There were some challenges when we first came and I don’t think staff had the opportunity previously to be open and say how they felt. We have an open-door policy ensuring staff day and night can talk to us.”

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 interim manager carried out a full assessment of people’s needs before they moved into the service, whether from home or hospital. Comments from people and their relatives included, “[I] had a care plan for respite, we spent 1 ½ hours with [manager]” and “I think they did the care plan with hospital staff, but they also talked to us.”

We observed visiting professionals supporting people and providing information for care staff. We received positive feedback from professionals who worked with the service.

One professional told us care for people had greatly improved since the new providers took over. Information was shared between staff and professionals to help embed good practice.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that.

Staff did not always complete mental capacity assessments and best interest decisions for specific decisions. Some care plans held contradictory information about people’s capacity for specific decisions. This meant staff did not always have clear and accurate guidance on how to best to support people. During the assessment, the provider started to review people’s care plans to ensure assessments accurately reflected people’s capacity to make specific decisions about their care.

The provider had a tracker for keeping a record of when applications for a Deprivation of Liberty Safeguards (DoLS) assessments were made. Some of the information required updating. The provider acted on this during the assessment.

However, the provider reviewed accidents and incidents, analysing themes and trends putting in measures to try to mitigate further risks to people. The provider was working on improving staff understanding of risk and when this needed to be reported through regular meetings with staff.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff did not always complete risk assessments relating to the health, safety and welfare of people using the service. This meant people did not always have care plans to support staff to manage risks. For example, specific risk assessments for the environment were missing. We also found some people’s care plans did not have individual risk assessments for the use of flammable creams. We raised this with the provider during the assessment who took action to remedy our concerns.

Despite our concerns, people and their relatives told us they felt safe at the home with comments including, “I feel safe, I am quite independent, can get dressed – need help with shoes and socks” and “I am quite content …happy.”

The provider did not always maintain a safe environment for people living in the service. During our inspection, we identified incorrect information recorded about people’s personal emergency evacuation plans (PEEP’s). We found 10 people’s PEEPs contained wrongly recorded details. One person was not living in the service anymore but was recorded as still being in 1 bedroom. This meant in the event of a fire people were at risk of not being supported in a timely manner. We raised these concerns with the provider who took action to ensure these were amended by the following day.

We saw a damaged shed storing cleaning products including those that were hazardous to health (Control of Substances Hazardous to Health - COSHH) had been raised in a senior staff meeting in November 2025 with the interim manager recording that the ‘COSHH SHED floor is unsafe and requires replacement.’ This had still not been actioned from when it was initially raised in a senior staff meeting in August 2025. In December 2025, the environmental audit looking at the external environment did not record any issues with the shed and confirmed that the external areas were well maintained and hazard free. The provider had failed to take the necessary action to make this safe and ensure equipment was being stored correctly. 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. We raised this with provider during our assessment who actioned the replacement of the shed straight away.

However, the service had a system to ensure the required health and safety checks were completed. This included equipment checks, fire drills, water testing and lift maintenance records. However, some daily equipment checks had not always been signed and there were gaps at the weekend or when the maintenance staff were off. It was not clear who took over this responsibility of these checks during these times.

Staff communicated any concerns in a book that was checked daily by the maintenance man. We saw some issues that had been reported dating back to October 2025 had not been marked as

completed and jobs that did have completed next to them did not record a completion date. The maintenance staff member was new in post but demonstrated a good understanding of what the role required.

The provider informed us since taking over they had undertaken refurbishment and renovation within the home to bedrooms and were working their way through communal living spaces.

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. We saw a letter dated in September 2025 which indicated a clear lack of knowledge and skills to effectively support people at this service amongst the staffing team.

Staff training was not all up to date at the time of this inspection. We saw gaps across different staff roles including the senior staff and interim manager. Housekeeping staff had not completed face to face training in dementia despite being around people daily who had a diagnosis of dementia. Staff had only received basic raining in supporting people with a learning disability and autism despite supporting some people with those needs. Following this inspection, the provider wrote to us and was open in stating training was not all completed for staff. They told us ensuring all staff were equipped with essential skills and knowledge for the job was ongoing.

However, the provider implemented safe recruitment practices since they had taken over the service. For staff that had been employed before this time there was information on their staff file to explain why appropriate recruitment processes may not have been followed.

The service had a sponsorship licence and some staff were employed under this scheme. The management team were open in saying there had been some struggles with recruitment but had not been short staffed as current employees picked up extra shifts. We saw that some staff had opted out of normal working hours and were working an increased work pattern on a regular basis.

We saw the service had a new induction checklist to support staff in the first phase of employment. The induction would also include an allocated mentor and training that was face to face as well as online.

The service had moved some staff from a sister home to work alongside current staff to strengthen the team. There was also 2 new seniors, and a manager starting shortly. Staff told us they had supervisions with a senior member of staff, and we saw records of supervisions.These had not been happening regularly for all staff, but the acting manager told us these were 3 monthly and booked these in going forward.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

There was a lack of storage for equipment in the homes. We did see that bathrooms often appeared cluttered with laundry bins, or mobility aids. Housekeeping staff described how they had to carry cleaning products with them to each bedroom and go back and forth between the cleaning cupboards because they did not have trolleys and could not leave products unattended. There was also a report that at times cleaning equipment would be unavailable with 1staff commenting, “We run out of things we need, they have cut back on what staff can order, we keep waiting for things. Last week we kept asking where the order is, certain things you can’t run out of, but we had to wait.” Since our inspection, the provider has confirmed that cleaning trolleys have now been ordered.

We found the service was kept clean, and staff were observed during our visit undertaking this role well. There were a couple of areas of the home where we detected malodours, and this was raised with the provider. Staff had access to personal protective equipment (PPE) and understood how to wear this correctly to keep people and themselves safe. The service had a food hygiene rating of 5 awarded.

Housekeeping staff recorded areas they had cleaned in a folder. This evidenced the housekeeping team were conducting deep room cleans as well as shorter daily cleaning of rooms. Staff were not sure if anyone checked the cleaning or reviewed the folders. The management team told us senior staff completed a walk around and would check the cleaning and this was fed into the manager’s audit. This audit was brief and did not include checking storage facilities or speaking to people or staff.

The service did not ensure medicines were stored safely. We found an insulin pen kept inside a chest of drawers rather than in secure storage. Prescribed thickener was found outside of locked cupboards and medicines awaiting return to the pharmacy were not locked away. The unsafe use of medical devices was also observed. An oxygen concentrator was positioned directly against a wall despite the manufacturer’s requirement for a minimum clearance. This meant people were at increased risk of harm from poor medicine management.

Medicines for topical administration, including pain relief gel and prescribed emollients, were not entered onto the electronic medication administration records (eMAR). Without these items recorded on the eMAR, the provider could not demonstrate safe monitoring of medicines or ensure that all staff were aware of what had been given to residents and when.

Time critical medicines were not administered correctly. A person prescribed Parkinson’s Disease medicine received multiple doses more than 30 minutes early or late. Time-sensitive medicines were also not given at appropriate times. For example, 2 different medicines to be given 30 minutes to 1 hour before food were incorrectly given with food. We observed a staff member crushing a tablet without appropriate authorisation during a medicines round. These failings meant peoples medicines were not administered in a safe, consistent, or clinically appropriate way.

Medicines given covertly (disguised in food or drink) were not carried out safely. A person receiving medicines covertly did not have a best interest decision made with all the relevant people present or pharmaceutical advice on how to give the medicines safely . This meant the provider was administering covert medicines without the necessary safeguards required.

A wider review of medicines management by medicine inspectors management for 5 residents identified failures , including medicines delivered to the service were not always correctly checked in on arrival and therefore were not always placed into the medication trolley in a timely way. As a result of these omissions, 1 person had not received their required treatment for several days, even though the medicine was in stock. We saw missing open dates on insulin pens and liquid medicines.

When required medicine (PRN) protocols did not always include clear guidance on how to assess the medicine's effectiveness or the next steps to take based on the outcome. This lack of

detail increased the risk of inconsistent care and made it difficult for staff to make informed decisions. Laxatives were administered as PRN medicines when a person had a bowel movement despite not being prescribed PRN, meaning staff were making prescribing decisions not authorised by a prescriber.

The provider failed to complete fire risk assessments for people who were prescribed paraffin-based emollients. Without documented risk assessments, the provider could not demonstrate they had identified fire hazards, implemented safety measures, or provided appropriate fire‑safety advice to people using these products.

Staff were unsure about the process for receiving or implementing Medicines and Healthcare products Regulatory Agency (MHRA) and patient safety alerts. This meant important safety information might be missed, delayed, or not followed, increasing the risk of avoidable harm to people using the service.

Audits were completed by management every 2 weeks; however, they were ineffective because they did not identify the issues we identified during our inspections of medicines.

The provider was accepting of our findings and started to act on the concerns identified following the assessment.

We have issued a Warning Notice as the registered person failed to comply with regulation 12 safe care and treatment in relation to medicines management.