Highborder 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.

This is the first assessment for this service. This key question has been rated 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 legal regulation in relation to good governance.

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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Whilst the new provider was working hard to embed a positive culture within the home and work with staff to embrace their values and ethos, time was needed to fully embed this into practice.

We received mixed reports about the culture of the home. A staff member told us, “Staff morale is not good at the moment, people are not happy, not sure if managers know. Staff are tired of all changes and can’t keep up with it.” Another said, “We have regular staff meetings and night staff meetings as well where we can bring forward our concerns at these meetings. They will report changes and improvements back to us.”

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively. At the time of the assessment, the service was managed by an interim manager. Whilst they had a strong skill set they were not onsite all of the time. This meant on some days during the week the service lacked the management skills and knowledge needed to run the home safely. The provider told us there was a plan when the interim manager wasn’t around to have support from outside of the service, including provider visits. We were not assured this plan was sufficient in the day to day running of the service. However, since our assessment, a new manager who is local to the area has started in post.

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

Staff told us they understood how to raise concerns and felt the leadership team were approachable. A staff member told us, “Yes, we can speak up. We have 4 directors which are very approachable and we have their numbers; we can always ring if we have any issues. The manager and deputy are both very helpful.” And another said, “I know I can speak up. I think they were trying to sort nominees out, but we mainly deal with seniors and managers. We could also speak to HR.”

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. The provider recognised staff contribution, celebrating events. The service had a diverse workforce.We observed staff working well together. Some staff told us the provider supported work life balance. One told us, “I have not had any issues, I take on the shifts that work around my childcare” and another said, “When new company took over they gave us option over what type of work contracts worked to fit around our lives.”

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

We found the provider was in breach of regulation relating to good governance.

There was a lack of provider oversight and governance systems had been limited in ensuring high-quality safe care. There was insufficient input at provider level to support the management and staff in implementing improvements needed and embedding change and fostering a positive culture within the service.

Whilst the provider had a governance system for the service , it had not had enough time to fully embed and be effective. The provider reviewed and monitored its service improvement plan, auditing and undertook spot checks of the service . However, there were gaps in some areas, and shortfalls had not always been identified by these audits . This meant the provider was not

identified improvements were needed in governance of the service, building staff skills and knowledge, risk management, medicine management and the environment.

The provider listened to our concerns and started to make changes during the assessment.

Despite the concerns we identified during our assessment, people and their relatives were generally happy with the service provided, people felt safe and well cared for.

identifying all areas for improvement we found during the assessment, potentially putting people at risk of harm. We

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 together to drive improvement. The provider collaborated with key organisations to support care provision particularly for people at end of life. The provider had signed up for an end-of-life training programme that supports staff dealing and caring for people at the end of their life. The provider was coordinating with a local authority care home support team to support staff regarding best practice around end of life.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. Whilst we found some significant shortfalls during the assessment which the provider had not identified with their own governance systems, the provider wanted to improve the service.This was reflected in their vision going forward. The provider shared with us the improvement plan for the service. They were open about the challenges they faced when they took over the service. Since taking over the service, they had developed new staff rotas to better suit the needs of the people living at the service. They had also invested in a new training provider, developed relationships with professionals who regularly visited the service such as community nurses and were working on improving the culture within the home. This included promoting people’s needs come first. They were working on improving people’s living environment and the external area of the building. The provider met with staff to discuss changes, vision and expectations.

Some staff told us the provider was open to suggestions for improvements. With comments including, “Suggestions for everything is welcome, we go to the deputy manager or manager and they are very open to suggestions.” However, some staff said the provider was not open to new ideas.

Visiting professionals told us the staff listened to advice and acted on direction given, to better support people’s care, with 1 telling us about their experience: “They have really listened and acted very quickly, the [manager] listened to my concerns and acted on them. The resident care needs [are] definitely now being met and they are much happier.”

Whilst the provider was focussed on improving the service it needed time to fully embed across the service. The provider acknowledged this.