The 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.

At our last assessment of this service, we found a breach in relation to safe care and treatment. At this assessment, we found the provider was no longer in breach of regulation and improvements had been made, but further work was needed to improve the rating.

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 had a culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to identify and embed good practice. However, these were not always effective due to staff not following guidance provided. For example, propping fire doors open.

Incidents and accidents were analysed and measures put in place to reduce the risk of them happening again. The lessons learned were shared with the staff team to ensure they were aware of any changes and how to mitigate risks, this included in monthly staff meetings. Monthly topics were identified and these were discussed in staff meetings, including handouts and the policies and procedures relating to these topics.

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.

Assessments were undertaken on people’s needs prior to moving into the service, or as soon as possible if people were placed in an emergency. The service worked with other professionals involved in people’s care to support smooth transitions between services, where required.

In The Coach House unit, people were supported to develop their skills, where they were being assessed to move to more independent living.

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.

There were system in place intended to reduce the risks of abuse. This included safeguarding policies and procedures and training for staff. Staff confirmed they had received safeguarding training and understood their roles and responsibilities in reporting concerns. A staff member said, “I have had safeguarding training,” and they showed us a list of contacts which they could refer to if they needed to report an incident.

Where safeguarding incidents had occurred, these were documented and reported to the appropriate authorities, who were responsible for investigating safeguarding incidents. Records included what had happened, when it was reported, the outcomes and what actions were in place to reduce future risks.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). Records demonstrated DoLS applications were made where required. A record of DoLS, including those which had been authorised, where kept assisting the management team to identify when reviews were needed. A relative told us how they had been consulted and provided input in their family member’s DoLS application.

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.

People’s records included risk assessments and guidance for staff in how to reduce and manage risks. However, during our first visit, a person was walking with their heel out of their footwear increasing the risk of a trip or fall. Staff did not intervene to reduce risk until we pointed it out. A member of the management team gave an explanation about the person’s footwear; they were waiting for a more suitable pair as the person had a dressing on their toe. Although this explained the reason, it did not mitigate the risks of the person falling. On our second visit, we saw this person did have suitable footwear which was opened at the toe.

People told us they felt safe in the service, and relatives confirmed they felt their family members were safe. A person said, “I feel safe here, there are carers up there [pointing to the corridor].” A relative told us, “[Family member] is very safe and the staff love [family member].”

The registered manager told us how they supported a person who had capacity to make decisions, about their safety and how to reduce risks. The person was given information to make an informed choice and staff respected their decisions. This was confirmed by the person. A relative told us how they worked in partnership with the staff to reduce risks to their family member and was at risk of falling out of bed. They said, their family member had, “A crash mat down, [relative and management team] are trialling this, we report back to each other. We have got really good communication.”

Where people were at risk of pressure ulcers developing or deteriorating, they were supported to move position to reduce the risks. However, the records of repositioning were kept in two places, both paper and electronically. We had been provided with the paper records for which we found people were not always being supported in line with the recommended timescales in the care plans. Following feedback, the provider sent us the electronic versions of the documents, which also had gaps. The registered manager assured us that the ways of recording repositioning would be reviewed.

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.

Since our last assessment, improvements had been made, including window restrictors in place, wardrobes were secured to walls preventing the risks of them falling, and actions had been taken to assess and reduce risks of access to the loft area and staircases. There was a risk assessment in place relating to the use of the stairs and the registered manager told us how people’s needs and risks were assessed if they were using a first-floor bedroom.

At our last assessment we identified fire doors being propped open, at this assessment, we found several doors were fitted with magnetic openers, however a bedroom continued to have the fire door wedged open with, for example a chair. We discussed this with the registered manager, and this had been to allow easier access in and out of a room for a person who mobilised independently and they closed the door when they had been through. The provider confirmed they would address this to ensure a safer way of the person accessing their room.

The registered manager told us they had a permanent maintenance staff member, who was increasing walk around checks on the health and safety of the building with the registered manager. The registered manager’s monthly health and safety checks, included fire doors, window restrictors and general health and safety of the building. We could see actions were being taken, either immediately such as light bulb replacements or longer-term plans, such as replacing flooring on the ground floor.

During our first visit we saw the wooden paving to the covered area in the garden was rotting, which posed a risk of slips and trips, the registered manager told us this was planned to be addressed, by our second visit it had been made safe.

The fire risk assessment was dated 2019, there had been annual reviews and visit by the fire service, the last visit was April 2026 for which they had found the service compliant. The registered manager told us a new fire risk assessment was planned to be carried out on 3 August 2026. In addition to the annual fire staff training, further training had been arranged in August 2026, including evacuation with the use of equipment. The provider confirmed they were looking at dedicated staff to be provided with Fire Marshall training. Fire drills and fire safety checks were being undertaken to reduce risks.

Water temperatures were being checked and flushing of little used outlets. There were certificates to show the water system had been tested for legionella bacteria annually with the most recent being in February 2026, with no trace and further check by a water company stating compliance in June 2026. The registered manager and provider confirmed they would look into a legionella risk assessment undertaken by a competent person.

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.

There was a dependency tool in place which supported the management team to calculate the numbers of staff required to meet people’s needs, this was kept under review. A staff member told us, “The staff increases as the residents increase, so I believe we are enough compared to the ratio of the residents.” A member of the management team told us when completing the staff rota, they took account the gender of staff and balanced staff skills and approach.

The registered manager told us how they had worked with commissioners for additional funding relating to people who had complex needs and required additional support. This was being used to have an additional staff member was on each shift.

We received mixed views from staff relating to if there were enough of them to meet people’s needs. A staff member told us, “Staffing levels are generally sufficient to meet the needs of the service. Our workloads are heavy, and if anyone calls in sick, it becomes very difficult to cover the shift and meet everyone's needs on time.” People told us they felt the staff were available when they needed assistance, however, we also received feedback from people that staff were often too busy to spend time chatting with them. A relative said, “I believe they do have enough staff; they do have someone monitoring the lounge, staff levels I am quite happy about.”

Records showed staff were recruited safely. Staff undertook a 12 week induction and probation. New staff were advised of their roles and responsibilities, undertook training such as fire safety and moving and handling, and were observed in their role and shadowed existing staff on all shifts. A staff member said, “I received an induction that helped prepare me for my role.” A member of the management team told us they undertook induction checks, including monitoring staff progress, coaching in areas such as how to apply creams; and staff understanding of the training they had received.

Ongoing training was provided to staff, including refresher training at set timescales. This was kept under review and staff advised when they needed to do their online training. Staff also received face to face training in subjects such as moving and handling. The deputy manager had been trained to train staff in medicine administration and moving and handling. As well as providing this face-to-face training, they undertook staff competencies.

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.

The service was visibly clean, however, due to the scuffs on walls and chipped paintwork, it was difficult to identify if these areas were cleaned thoroughly. Feedback from people and relatives told us they felt the service was kept clean. A relative said, “The room and landing are spotlessly clean, seems to be clean and well kept.”

Although there were infection control audits in place, we identified some risks of cross contamination which had not been picked up and addressed. The design of the toilet brushes did not ensure they were not sitting in unclean water, when in the holders. The registered manager took action and ordered new ones. A toilet riser was rusted which did not support thorough cleaning. The registered manager replaced this. Some jugs of drinks did not have lids on to reduce the risks of bugs or dust contamination. The registered manager assured us this would be addressed.

During our visit we saw staff wearing personal protective equipment (PPE) appropriately. A relative told us, “Staff have aprons and gloves on.” When staff were providing people with their choice of snacks, these were provided with tongs to reduce the risk of cross contamination.

The food hygiene certificate showed they had received the highest rating in 2025. Following our visits, the registered manager told us another visit by the Food Standards Agency had been undertaken, and they had maintained their rating of 5.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Systems were in place to ensure people’s medicines were available when needed and were stored safely. Staff were trained in administering medicines and their competency checked. People told us they were satisfied with how staff supported them with their medicines. A person said, “Tablets twice a day, have them when I want them.” A relative told us, “Medicines are managed well.”

Medicine audits assisted the management team to identify shortfalls and address them, such as monitoring gaps in medicine administration records to ensure people have received their medicines and retraining staff. However, during our first visit, we noted although the staff member locked the medicine trolley when they left it unattended, there were items, including medicines, on the top of the trolley. The registered manager told us they would look into this.

There were some prescribed creams left unsecured in people’s bedrooms, despite a lockable cabinet being in place. The registered manager told us some people independently administered their creams. However, they would revisit the storage of creams to reduce risks of people accessing and accidentally ingesting them.

People told us they received support with the application of their prescribed creams, where required. However, we found gaps in the paper records which identified when people were provided with these medicines. The application of creams were also recorded in the electronic daily notes. The registered manager told us they would consider how creams were recorded and ensure they were in one place to assist them to check if there were any gaps.

A person was prescribed medicated shampoo to be used twice weekly, records did not demonstrate this was being provided, with only one application over 12 days. We fed this back to the deputy manager who told us this would be investigated.

Where people required medicines to be administered as required (PRN) there were protocols in place.