Sobell Lodge - Care Home Physical Disabilities

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• 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 changed to 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 2 legal regulations in relation to safe care and treatment, and safe and effective staffing levels.

This service scored 44 (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 consistently demonstrate a proactive or positive safety culture grounded in openness and honesty. Staff did not always respond to safety concerns, nor did they reliably investigate or report safety incidents. Learning from incidents was not routinely embedded to support continuous improvement.

Although staff were aware of the systems for reporting incidents and for responding when things went wrong, there were concerns that not all staff fully understood what should be considered an incident. As a result, not all incidents were reported. Relatives report a high level of person-to-person incident and the incident log reviewed did not reflect this. Staff confirmed that there were incidents of people’s behaviour that challenged them and others. A staff member told us, “I feel that sometimes staff can be a bit lax in this area. For instance, I might come in on a Monday and hear that something happened over the weekend, and when I ask if an incident report was completed, they say no. So, I feel that side of things is not great.” Another staff member said they did not always know what happened after they submitted an incident or what learning resulted from it. They explained, “We still use paper forms. When there is an incident, I complete the form and hand it to the management staff, but I don’t know what happens after that.”

Our review of incident monitoring records showed that some incidents had recurred within a 5 days period. For example, there were repeated incidents involving moving and handling tasks carried out by 1 staff member when 2 were required. This indicated that incidents were not always reviewed promptly or actions implemented quickly enough to prevent reoccurrence.

When we discussed this with the provider, they told us they had now introduced the practice of reviewing incidents during their daily flash meetings.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

During our visit, we observed staff supporting a person who was preparing to spend the weekend with their family. Staff ensured the person had all essential belongings and enough medication for their stay.

However, another relative explained that they were not always informed when their family member had attended a hospital appointment or given feedback from medical reviews, which meant they could not always follow-up appropriately. Professionals also told us that staff were not always aware of emerging risks or when referrals to other services were required. Although they reported some recent improvement, they said they had previously needed to repeatedly chase the service to submit referrals or involve other professionals. This had increased risks to people’s health and safety. For example, concerns about a person’s eating and drinking, and issues relating to skin integrity, had not been escalated promptly.

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. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately. People and their relatives generally told us they felt safe in the home. A person said, “Yes, I’m safe.” A relative commented, “My loved one is safe, the home is safe.” However, 1 person expressed concerns about other people’s behaviour in the service that threated them and made them feel unsafe. They also said staff did not always take their concerns seriously and sometimes ignored them making them feel like the problem.

A relative expressed concerns about the number of person‑to‑person incidents occurring within the service. They told us this made their family member feel frightened, and they felt staff were not taking sufficient steps to safeguard people.

Records showed that staff had completed safeguarding training and were able to describe the signs of abuse and the process for reporting concerns. However, we found that safeguarding matters involving people were not consistently reported to the local authority or to CQC.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. We found some areas of risks people faced had been assessed. For example, we saw risk assessment and management plans for managing a person’s pressure sores and a choking risk assessment.

We found that staff were not always following moving and handling plans that were in place. Prior to our assessment, there had been two occasions, five days apart, where staff carried out moving and handling tasks in an unsafe manner. A person told us, “Staff sometimes don’t know how to put sling on and its dangerous. It’s alright if you get the same ones but if you get new ones, it can be a disaster. Some of the agency staff don’t always put the middle bit on the hoist, one day last week, the staff did not hook it through. For people who can’t talk it is dangerous.”

We also found some risks people faced were not identified, and where risks were known, assessments and plans were either missing or failed to guide staff practice. We found no risk assessment for a person who had a catheter. This meant staff did not have guidance on preventing infection, recognising complications or responding to catheter‑related concerns. In the absence of a plan, staff were reliant on their knowledge, increasing the likelihood of inconsistent and unsafe care.

We also reviewed Personal Emergency Evacuation Plans (PEEPs) and found they were not detailed to keep people safe, particularly in relation to moving and handling methods. For example, PEEPs we reviewed instructed staff to, “Firstly, put residents’ duvet onto the floor and pull them off the bed onto this using the mattress sheet. Then pull them on the duvet internally through the home away from the fire.” This method posed significant manual handling, dignity and injury risks. The approach was not consistent with safe moving and handling practice and risked harm to both the person and staff. It also failed to consider whether safer evacuation equipment (such as ski sheets, evacuation mats or slide boards) should be used. These examples show that the provider was not assessing risks in a structured or person‑centred way, nor were they ensuring staff had the right equipment available to support people safely. During our feedback the provider told us that they had purchased appropriately moving and handling equipment to help with evacuating people safely.

The provider had not always identified, addressed or effectively managed potential risks within the care environment, which had the potential to impact people’s safety and wellbeing.

A fire risk assessment was completed annually. However, a recommendation made by the assessor in 2024 had not yet been implemented. Further details are outlined in the Well‑led section of this report.
We found that fire evacuation risks during night‑time hours had not been fully assessed. Records showed fire drills for day staff, but there was no evidence that drills had been completed for night staff, when staffing levels were significantly reduced. Several people required the assistance of two staff to evacuate safely from bed. This meant that, in the event of a night‑time fire, staff may not have been able to evacuate people quickly or safely, placing them at increased risk of significant harm due to delays or insufficient staffing.

The service held up-to-date gas safety, water system, electrical installation and portable appliance testing (PAT) certificates. These checks helped identify potential hazards and ensured appropriate control measures were in place.

Health and safety equipment was serviced at appropriate intervals by qualified contractors. Maintenance staff also completed routine checks of the premises, including the monitoring and testing of fire safety systems. These arrangements supported the maintenance of a safe environment for people.

The provider did not 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 work together well to provide safe care that met people’s individual needs.

We received mixed feedback from people and their relatives regarding staffing levels. Some people told us there were enough staff available, while others reported shortage of staff resulting in delays in receiving support. A person said, “We need more staff… sometimes staff haven’t got time to do anything for us.” A relative commented, “I think there is shortage of staff especially at weekends and there are a lot of agency staff. Sometimes my loved one is left waiting to go to the toilet, especially at night.”

Staff also told us they felt staffing levels were insufficient. A staff member said, “We really need more staff. At the moment there are only 6 carers and a team leader, and we’re struggling because we have to get people up and also deliver breakfast. If residents need full support with their breakfast, that takes time. Quite often, we can’t get everyone up until 12:00 or even 12:30 and it is frustrating for the resident.” Another staff member explained, “Sometimes we struggle with staffing, and it can be overwhelming. We have 6 staff on the ground, but if staff call in sick it is a real struggle. We do need more staff throughout the day.” A further member of staff said, “There is not enough staff. We are rushed all the time, and I don’t feel like we have enough time with the people we are supporting. Their needs are far greater, and when we raise this, it’s not taken into consideration.”

During our visit, we observed that staff were busy and often task‑focused. People approached staff with requests, but staff were not always able to give the person the attention they need. At lunchtime, staff were focused on delivering meals and supporting those who required assistance, leaving limited opportunity for meaningful interaction.

The rota reflected the staffing levels planned using the dependency tool and showed the number of staff scheduled and present on the day. However, the dependency tool did not demonstrate how these staffing figures had been calculated, so we could not be assured that the staffing levels recorded were accurate.

Training records showed staff had completed training in core areas of their job roles. However, staff had not been provided with training relevant to people’s specific health and support needs such as positive behaviour management, and dementia. A staff member commented, “I would like more in depth training for dementia because we are getting more people with dementia, and now we are receiving more people with behavioural issues and would like more in depth training to support us.” Another staff member stated, “I think the training is sufficient to a point. I find the practical training sessions really good like the Oliver McGowan training or moving and handling training. I feel like the role is more than that of a care worker. It is rather support work. There is a lot more involved around supporting the people with behaviours and we need more training to do that for sure.”

Staff were not consistently supported through regular supervision to enable them to be effective in their roles. A staff member told us, “I have had a supervision this month and it went well. I had my appraisal back in summer. It has been challenging recently in the service because everyone’s been busy and we’ve not had service managers. Supervisions have not been happening quite as often as they should be.” Another said, “I had a supervision on the 02 December 2025 but before this one it’s been a while, but I can go to my deputy if I need any support with anything.” We reviewed supervision and development records for 7 staff members over a 12‑month period. All had received fewer than 3 supervision meetings during that time with 5 staff only having 1 recorded meeting. The provider’s policy stated that staff should receive, ‘At least 4 support and development meetings a year’. Current practice did not meet this requirement, and the lack of regular structured supervision meant staff did not always receive the formal support, reflection time, and guidance necessary to maintain and develop their skills.

The provider ensured new staff were recruited safely and had completed all necessary checks.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

During the inspection, we found that the home environment was not clean. The flooring in several areas was visibly dirty and sticky, indicating that effective cleaning routines were not consistently being followed. A relative also commented that their loved one’s room was not always clean. This posed an avoidable risk to people, as poor environmental cleanliness can contribute to infection risks and reduce overall safety and comfort within the home.

Staff had received training in infection control and food hygiene. They knew to use personal protective equipment (PPE) where required, such as gloves and other items of clothing that protected people from the spread of infection.

The manager told us they had reviewed their cleaning schedules and were monitoring it to ensure the environment always meets expected standards of hygiene.

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

People received their medicines as prescribed, including those who required time‑sensitive medicines. Medicines were managed safely and effectively across the service.

Staff demonstrated a good understanding of the service’s medicines procedures and followed them consistently. Only staff who had completed appropriate medicines training and had been assessed as competent were permitted to administer medicines.

People consented to their medicines, and regular medication reviews were carried out to ensure treatments remained appropriate and effective.

As part of the inspection, we reviewed the medicine administration record (MAR) sheets covering the 3-week period prior to the visit. These were completed fully and accurately, showing that staff administered medicines according to prescribed instructions.

Medicines were securely stored in a locked trolley within the medicine room, and access was restricted to authorised staff. The temperature of the medicine room was monitored routinely to ensure medicines were stored within safe ranges and maintained their potency.

There were effective systems in place for the receipt and return of medicines. Regular audits were completed, and audit reports showed that medicines were consistently accounted for, demonstrating effective oversight and governance of medicines management.