Claydon 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 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 legal regulation in relation to people’s safe care and treatment and the ways people’s prescribed medicines were managed.
 

This service scored 50 (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 ensured safety incidents were reported, investigated and used as an opportunity to learn and improve. For example, the service analysed falls to look for patterns and trends.

People and their relatives told us they were aware of how to raise safety concerns and who to approach. However, some feedback indicated that concerns were not always acted upon or managed to their satisfaction, which meant they did not have confidence in the service’s ability to learn and improve from issues raised.
 

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.

The provider had process in place to support safe systems, pathways, and transitions, for example, completing initial assessments with the person and their relatives prior to admission, and ensuring prompt care planning was in place. People and their relatives consistently told us the referral process went smoothly and no concerns were identified.
 

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.

Some people told us they were not always supported with their basic care needs, including a lack of support with toileting, personal hygiene, and oral care. This represents a risk of neglect and a failure to uphold people’s dignity and wellbeing. Some relatives told us they felt fearful of repercussions to their family member if they raised concerns, indicating a culture where people did not always feel confident speaking up.

However, people did tell us they felt safe living at the home and knew how to raise any concerns should they need too. Safeguarding information was available throughout the service, to inform people how they can raise concerns.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes/hospitals, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that where people were subject to a deprivation of liberty, the provider had implemented appropriate safeguards and processes.
 

The provider’s systems were not always effective in ensuring risks were clearly identified, appropriately mitigated, and managed in partnership with people. The service did not ensure people were appropriately involved in managing risks relating to their care and support. Risk assessments were not consistently person-centred, with some risk assessments being generic and not tailored to the person. This meant people’s individual needs were not always reflected in how risks were assessed or managed.

The provider did not consistently follow best practice in responding to behaviour that communicates a need, emotion or distress. Where people showed signs of agitation or distress, Antecedent, Behaviour, Consequence (ABC) forms were not always completed to identify triggers and inform preventative strategies. In one example where ABC records had been completed, there was no evidence that this information had been used to develop or implement a Positive Behaviour Support (PBS) plan for the person. This limited the provider’s ability to proactively manage the person’s behaviours and reduce the risk of escalation.
 

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.

The environment was not consistently maintained to a standard which ensured people’s safety, comfort, and wellbeing. The premises required general maintenance and refurbishment in several areas. Issues identified included damaged or missing ceiling tiles, worn or broken bathroom tiles, and missing door handles, which could pose potential hazards and negatively impact the overall safety and appearance of the environment.
 

The provider did not always ensure staffing arrangements supported the safety and wellbeing of people using the service.

Whilst staffing levels during the inspection were sufficient to meet people’s immediate needs, this was not consistently reflected in feedback from people using the service and their relatives. People and their relatives consistently told us there were not always enough staff available, which meant people did not always receive support in a timely manner.
 

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Infection prevention and control (IPC) practices were not consistently followed, which meant risks to people’s health were not always effectively managed.

Kitchen areas were not maintained to a clean and hygienic standard, and food hygiene practices were not always adhered to, increasing the risk of cross-contamination. For example, we found some of the kitchen areas to be unclean and food were not dated when opened. In addition, medicines administration was not consistently carried out in line with IPC principles, with staff decanting medicines onto table linen and reusing medicine pots for multiple people.

The provider’s IPC policies and procedures, and staff training, were not consistently implemented in practice. This demonstrated a gap between training, policy, and day-to-day practice, which increased the potential for health infections to spread within the service.
 

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

Staff did not always administer medicines in line with the provider’s medicines policy and procedures, and best practice guidance. We observed medicines being given without appropriate checks against the Medication Administration Record (MAR) charts.

We found people’s MAR charts which had been altered and did not align with prescription labels, with no evidence of authorisation or clinical guidance having been obtained from the prescribing GP. Some peoples MAR charts were damaged, with hole punches obscuring key instructions, meaning staff could not clearly read how medicines should be administered to people. We also found medicines loose within the trolley with no clear indication of who they had been prescribed for, increasing the risk of administration errors.
There was multiple stock discrepancies identified across medicines checked, indicating the provider had poor stock control processes in place.

People’s protocols for ‘as required’ (PRN) medicines lacked clear guidance, particularly where variable doses were prescribed. PRN medicines were being used to manage some people’s behaviours and people were being given prescribed medicines intended for occasional use on a regular basis. There were no clear records to evidence monitoring of the use of this PRN medicine and no records to demonstrate what de-escalation techniques had been attempted beforehand. This raised concerns about the appropriateness and safety of the use of people’s PRN medicines to ensure the least restrictive approaches to managing behaviours.

The provider’s quality monitoring systems were ineffective in identifying and addressing these risks. For example, a medicines audit, completed in June 2026 by the provider, stated their medicines check had found no issues and that no improvement actions were required. This demonstrated a failure of the provider’s medicine management and quality assurance processes.