Buckler's Lodge Care Home

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 the same. 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 legal regulations in relation to medicine management, safeguarding, staff training and support, duty of candour and staff recruitment.

This service scored 41 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events.We reviewed records such as handover notes and found a number of incident/accidents noted but it was not always clear how it was addressed or any actions taken to ensure timely support to people. For example, one person complained of pain in their private area. However, medical advice was not sought until the following day. The person was taken to hospital for treatment and it was confirmed as an infection. Another person was upset and distressed. Staff noted their skin integrity became worse. However, it was not clearly recorded how staff assessed the wound and if the barrier cream used was the most appropriate treatment for this person at that time.

Lessons were not consistently learnt to identify and embed good practice. Staff confirmed this was not happening regularly. There were incidents and accidents recorded relating to people’s care, support, emotional wellbeing or incidents between people. We found some incidents were recorded on behavioural charts and not always reviewed to identify any further action to support people. The provider did not always ensure incidents and accidents were thoroughly reviewed to help identify themes, triggers or trends that would require further action to be taken. There was some analysis completed for such events. However, it was not clear how this supported effective risk mitigation for people. It was not always evident how such information was used to adjust support to people, reduce the risk of recurrence and more stress to people.

Since the last inspection, there were incidents where the duty of candour applied. We discussed the duty of candour process with the registered manager. When notifiable safety incidents happened, people were supported to receive the required treatment and appropriate care was provided. We asked the management team to provide us with evidence that the regulation had been followed when those incidents happened. They were unable to demonstrate staff had consistently followed the regulation and their own policy to complete all the actions set out. Therefore, we were not always assured the provider had acted in an open and transparent way with relevant persons in relation to the incidents.

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.The provider and the registered manager did not always ensure they established or monitored safe systems to support the continuity of care. People’s care records did not always contain accurate information such as their care and support needs. Therefore, if people required hospital admission, inaccurate information could compromise people’s safety. Care plans and risk assessments had not always been kept up to date to show people’s current needs. Some staff noted they did not always have time to complete person-centred records. For example, for one person, the resuscitation form and advance care planning documentation were incomplete. Records stated a discussion was awaiting to review person’s wishes. However, there was no evidence any further attempts had been made to consult with the person or their family to plan further treatment. This indicated a missed opportunity to establish a clear and timely plan of care that reflected person’s preferences and any further medical support to be provided.Inaccurate information could be passed to other healthcare staff which could impact upon people’s treatment and support.

The registered manager explained how they prepared for admissions including gathering information from people and their families; or when people needed to move between services such as hospital admissions.Relatives agreed they were involved and informed regarding their family members wellbeing as and when they required treatment from different services. However, people were not always sure if they had any plans of care. From the records reviewed during the visit, it was not always clear if professionals were contacted appropriately and in a timely manner to support people with medical needs and ensure continuity of care.The registered manager did not ensure they had regular meetings or discussions with the staff team about people’s needs, any issues were picked up in a timely manner and addressed, and staff informed what should be done. Some staff said they were not always aware which staff worked on the shift. They felt this did not support effective planning of the work for the day in advance. Other staff agreed people’s care records were reviewed and they worked well with external services in partnership. Staff said they used a remote system to raise information with medical professionals to support any other action needed.Professionals provided some positive feedback regarding the service supporting people with different services.

The provider 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 always ensure that the staff team and the registered manager shared concerns quickly and appropriately.The provider did not ensure the system in place to protect people from abuse and improper treatment was used effectively.We found incidents where safeguarding alerts were not raised to ensure they were investigated properly. By failing to inform the relevant authorities of the allegations of abuse, placed people at risk of ongoing harm or abuse. This meant the provider and the staff were not always fully aware of procedures to follow. The registered manager responded to information given about alerts and raised it with the local authority. However, it was identified during our inspection and not through the provider's own governance checks.It demonstrated since our last inspection, the provider did not ensure they improved their process to monitor incidents and accidents consistently so that specific events were reported without delay to external agencies.

People told us they felt safe at the service and would be supported by staff if needed. They said, “I think it’s a very safe place, we’re being treated in a very particular manner. I don’t feel that anyone would abuse you”, “The staff are all very, very pleasant which makes me feel safe” and “It’s safe because there are people around and I have a bell to press and people respond in minutes.”Relatives added, “100% safe, the carers are amazing here. The carers are very kind and compassionate. I work in care so I’ve seen a lot and they can’t be faulted” and “It’s 100%, everything is safe, from getting in, codes on each floor and communications.”People told us if they needed help, they would seek staff or their family support to raise any issues.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. 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 MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS).

The registered manager told us they had made DoLS referrals for people to ensure appropriate legal authorisations were in place when needed to deprive a person of their liberty. They provided us with the tracker to monitor referrals and when the outcome was known.

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 had care plans and risk assessments in place with some details about their care and support. However, it was not always clear how the support or risk mitigation should be done. For example, one person was at risk of constipation and choking but there was no clear information how to manage such risk. Some people had a process to monitor and record their emotional wellbeing, but it was not always clear how the staff should support people or what guidance to follow to ensure positive outcomes.

Another person was receiving palliative care. The system showed that a wound assessment was overdue by 12 days, highlighting a lapse in clinical follow-up. The care plan did not clearly indicate if the person could continue having food, fluids and medication due to swallowing difficulties and risk of choking. This would put the person at risk of choking, particularly if an unfamiliar staff was allocated to support them.

A third person had catheter in place. Review of fluid balance records highlighted some further issues with catheter care documentation and monitoring. Staff had recorded a fluid intake and noted that the “night bag [was] taken off.” However, the entry lacked sufficient detail regarding further actions taken including if the low fluid intake had been escalated. This lack of clear documentation and clinical oversight was also raised with the management for immediate attention.

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.There were established systems for monitoring of the safety of the premises and the living environment. However, during both days of site visit we identified staff were not locking the doors that required to be locked. We reported this to the registered manager and the maintenance staff to ensure staff followed the signs on the doors. Not all staff received necessary fire training including to attend fire drills, to ensure they were aware how to evacuate promptly. We noted to the registered manager and maintenance staff to ensure they conducted fire drills at various times of the day. For example, particularly at night or late evening when the staff ratio was different to the day shift to ensure the staff team could confidently support people in the event of a fire.

We asked if the senior staff could support us to complete assessment to check if the service was designed to ensure it met the needs of people with dementia. We did not receive such support thus we completed the assessment and shared the findings with the registered manager. Some areas needed improvements. For example, clocks were noted in each communal space, however these were all different styles and in the lounge area the clock was very narrow and difficult to read the time clearly. The date was not displayed in communal areas. We observed one person could use a voice operated smart speaker in the main lounge/dining space. However, not all people had control over sounds and volumes. There were a few chairs to rest at the end of the corridors. There was a small sofa near the manager’s office, but we found it had an old stain on 1 of the cushions. The taps did not have clear indication of direction for hot and cold water, without signage for caution of hot water. The signage on the toilet door was small, and the picture used was not displayed in a bright colour. Signage on the walls to indicate direction or specific areas were not always obvious to ensure people could identify this from a distance. Toilet door was not painted in a distinctive colour. People were not always supported to engage in home life activities.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs. Not all staff had required training such as first aid depending on the role such as dysphagia; oral health, pressure area care; record keeping; safeguarding; moving and handling; mental capacity and DoLS. People had specific needs such as diabetes, epilepsy, Parkinsons, palliative care, catheter care and use of oxygen. However, it was not clear from the records if staff received specific training to be able to support people effectively and safely. Staff also told us they did not have training in most of these topics. It was not clear if staff assessing competencies in medicine administration were trained to be competent assessors. We found 3 staff did not have full competency assessments completed to ensure they were trained to administer medicine.

The provider did not always make sure staff received effective support, supervision and development. Staff told us they have not had supervision meetings, and some were not sure if their probation was completed. We observed some staff needed to improve how they responded to people. For example, we observed during lunch it was not always a great atmosphere between people and staff. One person struggled to move their chair to the table, another person started arguing with the person next to them for not helping tuck the chair in. The person started referring to a sheet of paper on the table. One person repeatedly told staff to leave them alone. Staff did not engage in meaningful conversations with people.

Staff deployment needed some improvements. For example, we observed the senior staff on different floors did not get involved to support busier times for people and staff such as lunchtime. Only 1 senior staff was helping during the lunchtime. We noted this was a missed opportunity for senior staff to observe, monitor and model staff's practice where needed, so people felt supported and engaged well.

We observed staff would congregate in one place rather than engage with people while they waited for food to be served. One person did not get their lunch until 1 hour later from the start of the lunchtime. We had to ask staff to ensure the person was offered something to eat. Another person was left sitting alone snoozing in the dining area without staff’s presence. We observed on another day that again 4 staff were congregated in the dining area rather than spending time with people. Some people told us they were not able to go out for a walk as there was no staff to support them.

Most staff told us they needed more staff to ensure they were able to compete tasks, spend more time with people and not feel overwhelmed. We noted to the registered manager the service had lots of good areas for people to get involved and do some activities including outside areas and a garden. But we did not observe staff were organised effectively to ensure people could go out or engage in different activities.

The provider did not always ensure all required recruitment checks and information were gathered before staff started work. We found information was missing such as gaps in employment history without explanation and evidence of conduct from previous employment working in health and social care. Records did not always include reasons why previous employment had ended. We found the provider did not always ensure Disclosure and Barring Service (DBS) checks were carried out before staff started working at the service. By failing to obtain all required recruitment information, the provider put people at risk of being supported by unsuitable staff.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. We observed dedicated staff team ensured the service was kept clean, tidy and malodour free. Staff followed a cleaning schedule and used appropriate personal protective equipment to help protect people from the risks relating to cross infection. This way the provider was preventing people, staff and visitors from catching and spreading infections.

People and relatives were complimentary of the service being clean and looked after. They said, “When we went for a walk, we had got mud all over the carpet in my room from the wheelchair but when we got back from having a cup of tea, they had cleaned it all up”, “Very good, my room is cleaned every morning. The cleaner always cleans my room when I’m at breakfast, so when I go back, it’s clean and my bed is made” and “It’s impeccable isn’t it. They even cleaned the car park straight after the fireworks display.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.For example, we identified 1 person had diabetes who had sweets kept for them to support an episode of hypoglycaemia. We asked staff about how to support a person if their glucose was low. The staff said we needed to speak to a senior staff about this. There was no senior staff around at that time for them to answer this query. Therefore, it was not clear how staff would manage this for the person. We reported this to the registered manager to address it with staff.

We were told there were no homely remedies but found some in the cupboard such as vitamins and pain relief gel. Another person used oxygen ‘as required’ (PRN) but it was not noted on the medicine list on provider’s electronic system to manage medicine. There was no PRN protocol or instructions in person’s care plan to check saturation levels and how this should be done. It was not clear what follow up care should be provided after oxygen has been stopped. The person had morphine allergy noted in breathing care plan, but it was on the system and was prescribed morphine. We raised this with the registered manager.We found half open medicine pack for one day’s dose. The packet still contained the tablets and 2 tablets were not noted on the system for that day. Another medicine should have been discarded after 4 weeks of opening in May 2025 but it was still there during our visit.

There was 1 person receiving medicine covertly. The care plan did not have clear information how to support the person to take medicine in a normal way and only use the covert process as the last resort. Usage of covert administration of medicine should be for as short time as possible. There were no clear dates noted when such administration should be reviewed or has been reviewed to check if there was still a need to use covert administration of medicine. Covert administration must be the least restrictive option after trying all other options. There was no clear evidence to show this practice was carried out by staff administering medicine to ensure the person was offered medicine overtly first. We did not receive a clear and detailed capacity assessment and that meaningful meetings were held to discuss best interest decisions for the person. Thus, making such process not fully justified or assessed properly.