- Care home
Saxon Lodge Residential Home Limited
We served a warning notice on Saxon Lodge Residential Home Limited on 24 August 2026 for failing to meet regulations related to the management of risk at Saxon Lodge Residential Home Limited.
Assessment report published 29 October 2026
Contents
Ratings
Our view of the service
Date of assessment: 2 July to 23 July 2026. Saxon Lodge Residential Home Limited is a residential home for people who require personal care. At the time of the inspection the service was supporting 21 people, some who were living with dementia.
The quality of the service had deteriorated since our last inspection. We found significant shortfalls, with 7 breaches of regulation to safe care, medicines management, governance of the service, staffing, dignity consent, responding to complaints and person centred care. In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward. Potential risks to people’s health and welfare had not always been assessed. Staff did not have detailed guidance to mitigate risks including how to de-escalate incidents of anxiety and distress. Staff had not always used assessment tools to identify continued risk to people’s health. Staff had not accurately recorded incidents to support learning, and external health professionals make decisions.
Staffing levels had been calculated using a dependency tool. However, the calculations had not considered all areas of people’s support, such as emotional support. There were not always enough staff on duty to provide people’s care and staff were expected to complete all the laundry and cleaning at night along with their care role. Staff were not always covered during leave or sickness.
The registered manager did not manage the service on a day to day basis; this was the role of the deputy manager. The registered manager completed monthly reports about the service. An action plan had been put in place but there were no timescales when shortfalls had been identified and when the action should be completed by. The registered manager had identified shortfalls such as care plans were not detailed but the action taken had not been effective and the shortfalls remained.
The culture within the service was not open and transparent, concerns had not always been investigated and acted upon. The registered manager and provider had not used complaints as learning opportunities to drive improvement. The registered manager had not notified CQC of safeguarding incidents as required. Medicines had not always been managed safely.
Staff had not always promoted people’s dignity or supported them in a person centred way. The registered manager had not acted to ensure received dignified care.
This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.
People's experience of this service
People we spoke with had mixed experiences of how they received their care and support. People who could express their choices, preferences and decisions verbally were happy with the care they received. They told us, they were supported to go into the community, staff used equipment to move them safely and they received support when they needed it.
However, some people who experienced anxiety and distress, did not feel their needs were understood or met by staff. Relatives told us, they had raised concerns about staff skills and knowledge when supporting people with emotional needs but no action had been taken to improve. Relatives told us, staff had called them to support their family member when they were distressed as staff did not know what to do.
People described how they had heard staff speak unkindly to people when they continually asked questions about where they were. People and relatives told us they had witnessed the management team and staff arguing amongst themselves, in the corridors and communal areas. This had increased some people’s anxiety.
Relatives told us they had raised concerns about staffing levels, staff skills and activities provision. Records confirm these concerns had been raised in relative meetings and quality assurance surveys but had not been investigated by the management team and continued.
People had not been offered choices in ways they could understand such at mealtimes. People were asked for their choice in the morning and by lunchtime some people had forgotten what they had ordered. The menu had not been provided in a pictorial form, and some people had not understood what food was available.