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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good.

This meant the service managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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.

The provider had made changes to staffing and there was now a permanent management team in place. The permanency off the staff was reflected in more consistent practice across the service. The provider had a vison for the service; they told us they were committed to continuing to improve. The management team lead by example treating people with dignity, patience and respect. We observed the manager engaging with people in a personable and caring way throughout the assessment. There was more focus on meaningful contact with people rather than on completing tasks.

The directors were visible and actively involved at the home. Directors supported people on day trips by driving the care home minibus.

The service often invited the local community into the home and worked with local schools to bring young and older people together.

The provider had inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Generally, the culture within the home had improved; the management team and the provider were visibly present in the service. The management team took the time to get to know people who lived there through spending time with people, this helped to improve staff’s understanding of people’s needs.

The provider told us they promoted honesty and accountability in all aspects of the service. The provider had been working hard with the staff team to support them to feel comfortable to bring any concerns they had to the management team. Meetings with staff took place. During the assessment we observed staff interacting with each other and the people who lived there.

Staff were praised and recognised for demonstrating the provider’s values and going above and beyond with people, through bonuses and certificates. Where staff had shown interest in other areas of work, opportunities to upskill had been given and further opportunities to progress and develop in the service offered.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

At our last assessment, we found the provider did not always have effective quality auditing and governance systems. At this assessment, we found the provider had made some improvements across the service. Further time was required to ensure improved practices were embedded and formed an on-going part of the providers governance, and auditing systems.

Improvements had been made to the oversight, monitoring and management of service systems and processes. These included identifying and mitigating risk, improved recording, audit checks to identify where improvements were required and oversight processes. However, these checks did not always identify where shortfalls within the service. For example, care plans held conflicting information about people’s needs. Whilst the provider told us this was a system issue; at the time of our assessment no action had been taken to rectify this. This meant staff were not always able to understand peoples care needs accurately and this was consistently putting people at risk.

These inconsistencies meant it was unclear whether all identified risks were documented consistently across the care plan.

Whilst the provider had an action plan in place for the service to work through the improvements required, which was updated during the assessment. The provider’s governance systems had not identified inconsistences we identified during the assessment. Including PEEPS (people’s personal evacuation plans) and some monitoring of people’s needs. The provider told us following our assessment they were reviewing all people’s care plans to demonstrate people’s needs were recorded accurately and to demonstrate consistency. They recognised some staff needed more training on reviewing care plans. This needed time to embed and for staff training to take place.

The provider had changed the medicines audit process at the home. However, despite improvements to the medicine auditing, it failed to identify the issues we saw during our assessment. For example, initial training in the use of oxygen, risk assessments and management of pain patches. Staff recognised further improvements were needed in relation to medicines at the home and were committed to making these changes.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The acting manager and deputy were present on the floor and knew people and their families well, the manager’s office had been moved to a more prominent position in the building which gave better access for staff and people. Morning meetings with staff worked well to share information about people and any changes.

We observed improved interactions between people and staff and where people previously chose to remain in their room they were now eating with others and joining in communal activities more often. Staff appeared more confident in supporting some individuals since our last assessment. We observed more of a collective approach to involving people in activities in the home.

Where concerns with poor practice were identified, the provider addressed these promptly and ensured staff training and support needs were met. The provider was working hard to embed improved quality assurance processes, acting on findings quickly. The provider told us they wanted to reflect continuous improvement is a shared responsibility.