Godiva 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 inspection we rated this key question good. At this inspection the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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.

Accidents and incidents were recorded and analysed to identity any trends or patterns so actions could be taken to mitigate emerging risks. Processes ensured any learning was shared with staff through handovers and staff meetings, to ensure they had up to date information to support people safely.

One staff member told us, “If there is any chance a resident has fallen in the night, then we get that information at handover. You get told if you need to do more checks or if a referral is being made to the falls team.” Another staff member said, “Our records, about a year ago went electronic. All staff have a handheld device so they can check anything, and it alerts you if something has changed."

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’s needs were fully assessed before they moved into the home. This ensured the person’s needs could be safely met and assisted in making smooth transitions between services. Information gathered was used to develop care plans and risk assessments so staff had the information needed to provide safe, personalised care.

Staff knew people well and demonstrated a good understanding of their needs. Staff worked closely with health and social care professionals to ensure people achieved good outcomes. One staff member said, “As a team leader you always escort the doctor and then update the records based on what they say and make sure the staff know. Say the doctor prescribed antibiotics."

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.

People felt safe living at Godiva Lodge. One person said, “I feel quite safe, there’s always people around.” A relative told us, “[Person] is safe, the staff are always checking on them.”

Staff had received safeguarding training and understood their responsibilities to keep people safe. One staff member told us, “I would report any concerns to the manager. It’s not good to assume just because they are living with dementia, they don’t know what they are saying.”

Records showed the registered manager had referred safeguarding incidents to the Local Authority (LA) and Care Quality Commission (CQC) appropriately.

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.

Care records informed staff about risks associated with people’s health and wellbeing and the action they needed to take to mitigate identified risks. For example, 1 person’s care records included recommendations made by a health care professional to mitigate the risk of developing breakdown to their skin. Records confirmed staff had followed this instruction.

Care records and risk management plans had been regularly reviewed and updated where needed.

The provider did not always detect potential risks in the home. For example, environmental audits had not identified exposed pipes in a communal toilet and a potential trip hazard in a person’s bedroom. Furthermore, whilst running temperatures were controlled via thermostatic mixing values (TMV) we found the water pressure operating around the home fluctuated. TMVs are designed to operate effectively within a specific range of water pressure. This is important to protect people from the risk of scalding or burns. If water pressure exceeds the specified limits, it can affect the TMVs ability to maintain the required temperature. When we alerted the registered manager, they took action to address these safety concerns.

Guidance was in place for staff to follow on how to check equipment prior to use to ensure it was safe and in good working order.

Staff had completed fire safety training and took part in regular fire drills. Staff understood the action they needed to take to keep people safe in the event of a fire or other emergency. One staff member told us, “We have regular fire drills. I think that’s good as it keeps you on your toes. If the bells ring and you are helping a resident the first thing you do is make sure they are safe. Then you go to the front reception, closing any open doors as you pass by. In the reception a team leader will meet you and will tell you what to do. You follow their instruction which helps keep the residents safe."

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.

People were happy with the support they received from staff. One person said, “I think there’s plenty of staff, they are always around it you need them.” Another person told us, “I love all the staff here, not a bad one among them.”

Rotas demonstrated staffing levels were maintained and people were supported by a consistent staff team. One staff member told us, “We work well together if we are short. We would never have to do a 2-person job alone. Team leaders and managers help if needed, I feel well supported.” Another staff member said, “We all work closely here. If there is any change, big or small to a resident’s needs I am told straight away.”

Staff had been recruited safely in line with the provider’s policy and best practice guidance.

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

Staff did not always adhere to the provider’s ‘Cross Infection’ policy and procedure. For example, members of the management team and staff were observed working with uncovered facial piercings and wearing bracelets, rings and necklaces. The provider’s policy only permits the wearing of plain wedding bands and small plain ear studs.

Some staff practice did not promote good infection prevention and control. Red bags containing soiled laundry were placed on top of other clothing items in laundry baskets outside people’s bedrooms. This created the potential for the spread of infection and cross contamination if the bag split or if a person opened the bag. The registered manager told us, “Staff know the red bags should be taken straight to the laundry.”

Monthly infection control audits were not always effective. The latest audit dated 23 September 2025 had not identified the issues we found. This meant areas requiring improvement were not consistently identified and addressed.

Staff had completed infection, prevention and control training. One staff member told us, “We have good stocks of gloves and aprons which we always wear when providing any type of personal care.” Our observations confirmed this.

The laundry room was clean and well organised. Housekeeping records showed daily and weekly cleaning schedules for all areas in the home, had been completed.

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

Improvement was needed to ensure people’s medicines were consistently administered, stored and managed in line with the provider’s policy and procedures.

Topical medicines to be applied directly to people’s skin were stored in an allocated room on each hallway. These rooms were not locked in line with the provider’s policy which meant these medicines were easily accessible to people. This put people at risk of accidental ingestion or adverse skin reactions. Other medicines were stored safely.

Records had not been completed for a person whose prescribed medicine was administered via a patch applied to their skin. Recording where on the body each patch has been applied is important to ensure patch applications are rotated to prevent skin irritation or damage.

Homely remedies (over the counter medicines to treat minor aliments) were not managed in line with the provider’s policy and procedure. For example, administrations of these medicines had not been recorded on the electronic medicines system and in the homely remedies book. In addition, documented stocks of homely remedies did not match the physical stock available. The registered manager began to take actions to address the shortfalls we found.

Medicines were checked by 2 staff when received into the home and were disposed of safely. Staff had completed medicines training, and their practice was regularly reviewed.