Courtfield 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 Good. At this assessment the rating has remained Good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Safety incidents were appropriately investigated and reported. Staff could give examples of risk management and knew how to raise incident and accidents. Detailed audits were undertaken, with reports being sent and signed off by senior management.

Meetings took place where changes were needed such as sensor mats, referrals or safeguarding reports to keep all staff updated. A staff member said “I like that learning from things is important here, we might do something wrong, so we change it to be better”

Systems had been updated to ensure access to centrally accessible, real-time information to improve communication between the different homes, based on lessons learnt from previous management and an emergency within the home.

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.

People experienced a smooth process when they were referred into the home, pre-assessment paperwork was extremely detailed. After the initial assessment care staff were involved in sharing their views on whether they could meet individuals needs. Managers also considered the dynamics of people living within the home.

Hospital passports were detailed and supported safe transition between services when medical intervention was needed.

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 provider ensured staff received Safeguarding training. The provider had the appropriate policies, systems, processes and practices to protect people from abuse, neglect and harassment.

Staff across the organisation were aware of how to raise a safeguarding alert. A staff member said, “I am confident any concerns I raised would be addressed but I can report to the local authority if I need to, I know what to look for.” Another shared, “The manager would never ignore concerns, she’s all for protecting people.”

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 home was working within the principles of the MCA and how they managed DoLS within the home. We found that (DoLS) were applied for through the relevant local authority. Details of DoLS authorisations were documented in care plans, including review dates.

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.

Staff informed people about any risks and how to keep themselves safe and were confident staff knew how to support them to mitigate risk.

The home’s risk management and person-centred care policy demonstrated a philosophy of positive risk management and collaboration between, the individual, family/friends and the home. Evidence of this in practice was shown by an individual who chose to use a bed lever that came with their bed. Risks were explained to them, and the risk assessment was updated to document they understood the risks associated with its use.

Staff knew individuals well and this assisted in their understanding of different communication methods such as expressing different emotions or distress. Communication and emotional support needs were documented in care plans.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Required equipment was regularly serviced, monitored and maintained, by a designated maintenance staff member; repairs were arranged promptly when needed.

The home had suffered a fire in 2025. They had received praise from the fire service for their response to the situation. They had used the experience to establish lessons learnt and improve fire safety measures. Fire safety procedures and the correct equipment were in place. Personal emergency evacuation plan (PEEPS) were regularly reviewed and stored in the front entrance.

People were cared for in safe environments that were designed and adapted to meet their needs. Safety certificates were completed in line with legislative requirements.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The home utilised a dependency tool to calculate staffing levels which reflected the needs of people living in the home however some staff still felt that they were constantly busy, especially around peak times. Some family members also shared that they felt more staff were needed, especially at busy times including mornings and mealtimes, we found similar in our observations.

There were robust and safe recruitment processes to make sure that all staff including agency staff were suitably experienced and competent to carry out their role. Shadow shifts had been increased from 3 days to 6 days to ensure a more thorough induction experience especially for those new to care.

Staff at all levels have opportunities to learn and were supported to keep their professional practice and knowledge up-to date. Poor performance was managed appropriately.

We found some concerns regarding cleanliness in the home. People’s views on cleanliness were mixed, some people felt the home was clean “It’s very clean, it’s like being in a hotel,” whereas another family described how they had been unhappy with limescale in the bathroom.

Following our feedback new equipment was sourced, cleaning schedules adapted, and improvements were seen before the assessment was completed.

There were good stock levels of PPE, this ensured that people were protected as much as possible from the risk of infection. Staff were trained and understood their role regarding infection control, staff were able to share when it was necessary to wear PPE.

The provider made sure that medication and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

There was a clear approach to the safe use of medication, and staff understood their roles and responsibilities were understood. Staff were trained and regularly assessed as competent to manage and administer medications safely.

Controlled drugs were stored, recorded, administered and disposed of in line with legislation and guidance.

Staff used a pain monitoring app to establish baseline pain levels, this assisted in the correct use of PRN medications such as pain relief. A person told us, “They give me medication, I can ask for painkillers if I need them.”

The home had recently introduced a digital medication administration recording system. The quality team supported staff to manage the transition and ensure practice remained safe during the initial launch.