Healey Lodge Residential 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 changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to safe care and treatment, safe staffing levels, fit and proper persons employed and supporting people in a person-centred way.

This service scored 38 (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. Lessons were not always learnt to continually identify and embed good practice. Incident and accident forms were not always completed or did not always reflect the audits. There appeared to be confusion as to what an accident or an incident was and there was no evidence of lessons learnt, or sharing of information with the staff team when incidents occurred. It was not always clear whether people had skin damage, including pressure sores as records in this area were not robust. Records relating to re-positioning charts were not always completed in line with advice from professionals and these records were not consistent.

People and relatives told us incidents and accidents were managed well, however, some concerns were raised in relation to wheelchair suitability. Staff told us the process for falls and felt risks were minimal. One staff member said, “There are not many falls (occurring). If a person bangs their head, we carry out observations every 15 minutes and seek medical attention.” However, records relating to falls did not evidence consistent observations taking place.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. Hospital passports were in place. This is a document people take with them to hospital so hospital staff know how to safely care for a person. However, we found these records were not always up to date which could lead to a person not receiving the appropriate level of care in a hospital setting. Some concerns were raised in relation to the location of the setting. One relative said, “It is the most inappropriate place because of the distance. There was no where nearer.” Other concerns were raised over the service, and some relatives described the environment as ‘overwhelming.’

Most relatives did tell us people were happy living at this service and that people’s admissions were well managed. Staff told us the process for new people coming into the service. They said, “The (registered) manager writes the care plan and tells seniors (staff) about new admissions. This is handed over to all staff during handovers which are twice daily.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. However, not all staff were knowledgeable or trained in this area. Staff told us people were safe and knew the process for reporting any safeguarding concerns. However, not all staff were aware of DoLS (Deprivation of Liberty Safeguards) and what this meant in practice. Not all staff were aware of who had a DoLS in place or if anyone had any restrictions in place. Not all staff had completed training in safeguarding and there was no safeguarding lead at this service. The safeguarding policy did not include important details to guide staff such as the local authority or registered managers contact details.

We witnessed staff treating people well and did not observe any concerns relating to abuse or neglect. People told us they felt safe using this service and relatives said any concerns would be acted upon. The nominated individual told us all concerns were immediately reported to the senior staff on duty or the registered manager who would assess risk and refer as appropriate.

The provider did not work well with people to understand and manage risks. Relatives did not always feel risks were managed well. One relative raised concerns in relation to a person’s moving and handling provision and another relative raised concerns in relation to call bells and alarms and how the noise impacts on people using this service. We did notice during our site visits that nurse call bells sounded throughout the day and although staff appeared to respond in a timely manner, one alarm was placed at the dining room table where people ate their meals. This alarm was extremely loud and could cause distress to people. This was moved during our site visit.

Risk assessments were in place but were not always detailed or person-centred enough to guide staff on what to do should a person’s condition deteriorate, this included diabetes risk assessments. Moving and handling risk assessments for people who required a hoist and sling for transfers was not clear on what type of sling a person should use, including the size. This was rectified during our site visit. Monitoring charts relating to people’s distressed behaviours were not detailed enough and did not always evidence the outcome for a person. Not all staff felt distressed behaviours were well managed. One staff member said, “Staff do their best, but they have not had training in this area and don’t know how to manage it.” We did observe on several occasions people became distressed and staff did not always appear to know what to do. Lighters were found in a bedroom which were not secured. This posed a risk to people and was not in line with the providers smoking policy. This was rectified during our site visit.

Staff told us how the risk of choking was managed by following people’s specific plans and the use of thickening powders in drinks were prescribed as required.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. We observed a number of safety concerns throughout our site visits. One person’s bedroom had a hole in the door which could be dangerous should a fire occur and we saw extension leads plugged into further extension leads which could pose as a fire risk. Fire drills did not hold a robust account of who attended the drill and fire safety checks were not readily available on day 1 and day 2 of our site visits.

A storeroom was found to be unlocked containing several risks to people and the laundry room door had no lock on. This contained chemicals which were easily accessible to people. This was identified through manager audits in July 2025 then again in September 2025 and no action was taken to reduce this risk until we identified this during our site visit. Not all servicing checks were available on day 1 and day 2 of our site visits and we saw no evidence of bed and mattress checks or shower head cleaning as per the legionella risk assessment. The weighing scales were due to be serviced in February 2025 but were not serviced until our site visit.

People and relatives told us the environment was safe, and staff told us the process should a fire occur. One staff member said, “We have regular drills and either the (registered) manager or senior (staff) is appointed fire marshal. We have had fire marshal training. The process is the fire marshal sends 2 staff members to the zone, call 999 and (staff) meet in the reception area.”

The provider did not make sure staff were recruited safely and had the skills and knowledge they needed for their role. Staff recruitment processes were not robust. Interview notes were either not fully completed or not accurate and gaps in employment had not always been explored. Dates of application forms, interview notes and DBS (Disclosure and Barring Service) checks did not collate. Not all new staff had received a contract, and this service was not following their own recruitment policy. The management team were unaware of the previous issues found at the last inspection around staff recruitment.

Staff raised concerns relating to training requirements. One staff member said, “We do nothing face to face, we especially need moving and handling face to face.” Another staff member told us they only knew how to use the hoist due to their previous employment and had not been offered any training in this area. The training matrix identified gaps in staff knowledge and some staff had been employed for several months and not completed any mandatory training. The registered manager and nominated individual held conflicting views on how staff training provision would be managed moving forward.

Staff had mixed views on staffing levels. While some staff felt there were plenty of staff, others raised concerns in this area and felt there was a lack of staff in general at the service. We did notice staff presence throughout our site visits and the dependency tool evidenced there was enough staff. However, we did notice staff were very busy in the mornings and not always around to respond to people’s needs. Relatives told us there was enough staff. One relative said, “It is difficult to say about staff numbers or members. I don’t interact enough to see how many staff are about. There’s lots of milling about. The ones (staff) I know are very well trained. They all speak with passion and care.”

The provider did not always assess or manage the risk of infection. We observed several concerns relating to IPC (Infection Prevention and Control) at this service. The kitchen store had food stored on the floor and raw meat was mixed with fresh produce in the freezer which required defrosting. A new freezer was purchased during our site visit. A refurbishment plan was in place and ongoing works were taking place during our site visit. However, flooring was damaged and covered with tape which could pose as a trip hazard and prevent good cleaning practices and rust was found in some communal bathrooms. Some walls and door frames required painting. The cleaning file was detailed and the service appeared to be clean and tidy, however, gaps were noted, including domestic tasks on a Sunday and some forms were not dated so we could not be sure when certain cleaning tasks had taken place.

People and relatives told us the environment was clean. One relative said, “It is always clean and tidy. Bed is always made and it’s always clean.” Staff told us the service was clean and that there were plentiful supplies of PPE (Personal Protective Equipment).

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning. Temperature monitoring was being completed and recorded in areas where medicines were stored. Medicines, including controlled drugs were stored securely, however, we did find that controlled drugs records were not always completed correctly. MAR (Medication Administration Records), care plans, PRN protocols (for medicines that are taken ‘when required’), and Hospital Passports were available, however we found that they were not always accurate and had conflicting information. This means there was a risk of people receiving their medicines incorrectly which put them at risk of harm. Risk assessments were not up to date and did not reflect the current needs of people. Monthly reviews of documents to support people’s care and treatment were not robust and did not identify changes to people’s needs. This does not provide assurances that these reassessments were taking place effectively. We found that staff did not follow systems and processes when administering and recording the administration of medicines. Records showed that people received some medicines too close together which put them at risk of harm.

Some people required their fluids to be thickened to prevent the risk of choking. Records for the use of thickeners did not provide assurances that thickeners were being used correctly which put people at risk of harm. Topical creams (non-medicinal) were stored in locked containers within peoples’ bedrooms, ensuring they were stored safely and securely. However, there was no process in place to check the contents of service user’s cabinets and that they contained the correct creams. Staff competency checks were overdue for two staff members who required it. This was required by the service provider to be completed annually. This did not provide assurances that staff administering medicines were competent to do so.

Audits on medicines including MAR charts had not been effective at identifying the issues found on inspection. This means there was poor oversight of medicines. Medicines were supplied and delivered by a nominated pharmacy and arrangements were in place for obtaining advice during out of hours. There was good communication with the pharmacy on stock availability so that any issues could be identified early. There was a process in place for ordering medicines in a timely manner to ensure medication was available for people using the service.