Cheybassa Lodge Rest 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.

This is the first assessment for this newly registered service. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was in breach of legal regulation in relation to safe care and treatment and recruitment.

This service scored 28 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

When care had not gone according to plan, records were poorly completed and did not always include information about the actions which had been taken by the provider to keep people safe. This incomplete documentation limited the ability to review incidents effectively or identify patterns that could prevent future harm.For example, 7 medicine error forms had been completed in August 2025 but the section for manager completion and lessons learnt was blank. One medicine error had been repeated which could have been avoided if an effective system was in place to learn from.

The registered manager had recently implemented a service analysis tool to review safety events. However, this did not include all the incidents that had taken place such as medicine errors, people’s behaviours that challenged others and bruising of an unknown cause. When incidents had been recorded, effective measures had not always been implemented to ensure improvement and safe care. For example, ‘Possible time pressures or staff workload issues’ was recorded in relation to an incident but there was no further information about how this could be addressed or resolved. During our inspection we found that staff did not always have the time to support people effectively. This meant opportunities to identify trends, learn from incidents, and implement improvements to prevent future harm were missed. We also identified that when measures to improve safety had been recorded, they were not always followed. For example, staff were not always in the lounge during our inspection although this had been recorded as a measure to reduce some people’s falls and altercations between them. This increased the risk of harm for people.

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 carried out assessments prior to people being admitted to the service with the aim of ensuring their needs could be met. However, some areas of the assessments contained limited or confusing information to enable staff to provide effective care. For example, for 1 person who had most recently been admitted into the service, it stated in the ‘Pain’ section of the assessment, ‘I have moderate pain/fatigue’. The ‘skin’ section stated, ‘I have a history of pressure injuries’, ‘I have discoloured skin – grade 1 and ‘I have broken skin or a spot – grade 2-4. There was no further information for staff to know how to support the person with pain, fatigue or skin integrity. The ‘social’ section was blank. This meant staff would not know how to support the person effectively.

The electronic care plan that was used by the provider generated hospital passports in case a person needed to go to hospital. These included a copy of a person’s care plan. Although areas on care plans lacked personalised detail, these went some way to support a safe transition.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not 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 share concerns quickly and appropriately.

The provider had not raised all concerns of a safeguarding nature with the local authority safeguarding team. These included medicine errors, bruises of an unknown cause and when the service could not meet a person’s needs. This meant people were at risk of continued potential abuse.

In addition, we identified examples during our inspection when people were at risk of harm or poor care. These included concerns with risk management, medicines management, adequate hygiene and oral care and people’s behaviours. As a result of these concerns, we made safeguarding referrals to the local authority to ensure immediate protection.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks associated with people's health and wellbeing were not effectively assessed, monitored or mitigated. Risk assessments lacked sufficient detail to guide staff in reducing harm. For example, 2 people identified as high risk of falls had no clear information about how risks should be managed. Some people displayed behavioural and psychological symptoms of dementia, yet their risk assessments did not provide staff with appropriate strategies to support them. Behaviour monitoring records showed frequent emotional distress, but there was no evidence people were supported to reduce or prevent this.

Risk management measures recorded were not always followed. For example, on inspection days, equipment to reduce falls and prescribed food textures to prevent choking were not followed.

When risk assessments were in place they were not always effective. For example, 1 person was at risk of skin breakdown and following our inspection, a partner agency told us they had identified numerous pressure injuries on the person. This had not been picked up by staff at the service, indicating ineffective monitoring and response.

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.

Areas which posed risks to people were accessible. For example, people with mobility and cognitive issues which increased their risk of falls could access stairs. People who were at risk of ingesting harmful substances had access to the laundry room which contained chemicals. People who were at risk of choking and may not understand those risks had access to the kitchen, food items and thickening agents for drinks. This increased the risk of harm.

Environmental risks had not always been considered for those that lived there. For example, although the provider told us bed rails were not in use, these remained on people’s beds. These can increase the risk of limb entrapment and injury. Heated towel rails in people’s en-suites were not covered and although they had a label stating, 'caution hot surface’ consideration had not been given to those with a cognitive or visual impairment who may not be able to understand or see the labels. This increased the risk of burns.

Some people had specialist beds and mattresses. There were no records to demonstrate they had all been regularly serviced. On the second day of our inspection, 1 mattress was faulty. Professionals external to the service told us the fault was due to the pump not being serviced and was 3 months overdue. This increased the risk of pressure damage for the person using the mattress.

The risks associated with fire had not been sufficiently managed. There were fire safety issues that were identified on the provider’s fire risk assessment from approximately 1 year ago that continued to be a concern on this inspection. These included a lack of fire instruction signage and a lack of up-to-date information in the emergency evacuation folder. There were no records to demonstrate staff had received simulated fire drills to adequately prepare them for a potential fire and staff we spoke with did not demonstrate a clear understanding of how they would safely respond to a fire incident.

Checks to reduce the risk of Legionella did not always demonstrate this was in line with guidance from the Health and Safety Executive (HSE). This increased the risk of Legionella.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

During our inspection we observed a lack of staff which impacted on the care people received. People did not routinely have access to key elements of care, including, meaningful leisure time and emotional support. For example, we observed 2 people who displayed emotional distress, but staff were not available to support them. Other people spent most of their time in their bedrooms with minimal engagement from staff. Staff provided mixed feedback about staffing levels. For example, 1 staff member told us,” There’s enough staff and I can meet their [people’s] needs.” However, another staff member said, “At [time of day] it’s a nightmare, it’s so busy you’re running on autopilot”. “We shared our concerns with the provider during the inspection and staffing levels were increased as a result.

Staff provided mixed feedback about the training they received. For example, 1 staff member told us, “The training is really good. We do online training and in person training which has helped me a lot.” Another staff member said, “I don’t think it’s great, it’s online and you just get these trainings through in an email all in one go. I don’t feel I learn much.”

We noted some staff had completed or were expected to complete a high number of courses in a short space of time. For example, 1 staff member was given 19 days to complete 17 training courses. We were not assured staff would be able to retain this information. We discussed our concerns with leaders who told us that some of the training courses only took 20 minutes to complete. This meant we were not assured the training was of sufficient quality.

Although the provider had organised some training for staff, they did not always have the skills to support people safely or effectively. For example, staff had received training in oral hygiene, choking awareness, medicines and fire but we identified concerns in these areas during our inspection. Partner agencies shared these concerns.

Records did not demonstrate staff had received robust inductions. The service used temporary agency staff, and no inductions were available for them. This meant they may not have all the information needed to support people safely.

Staff were not consistently recruited to ensure they were suitable to work with vulnerable adults. Although not all recruitment records were available for us to review during our inspection, we identified concerns with the records that were in place. For example, there was a lack of information about how decisions were made about staff members suitability for the role, there were some gaps in staff members previous employment and there was not always evidence of satisfactory conduct in previous employment concerned where staff had worked with vulnerable people.

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

Records showed the service was cleaned regularly. However, some staff told us the cleaning arrangements were not sufficient. For example,1 staff member said, “I feel cleanliness could improve in some places, if the cleaner could stay longer that would help.” And another staff member said, “It’s [the home] not as clean as it should be.” The nominated individual told us they had plans to increase cleaning hours.

Some areas of the home and equipment used to support care were not always clean and free from the risk of cross contamination. For example, the shower room and shower chair. Most door handles had foam covering them and most of these of these were not clean. The poor cleanliness of the environment put people at increased risk of infectious diseases.

The laundry room was cluttered and unorganised without any effective protocols to separate clean and dirty laundry. Items such as vases, urine bottles, toiletries and cleaning products were stored in the laundry room. Bathrooms did not contain clinical waste bins and staff were observed to carry bags of clinical waste through communal areas to the clinical waste bag in the laundry room. This increased the risk of infectious diseases being spread.

Staff were observed wearing personal protective equipment (PPE) correctly during mealtimes and when assisting people. However, some PPE was stored in a communal space hanging from rails rather than in a designated cupboard to protect it from contamination. This meant we could not be assured PPE was being used in line with best practice.

Staff did not always have good knowledge of infection control practices such as the use of spillage kits to clean bodily fluids or what action they would take in the event of an outbreak. This increased the risk of infectious diseases being spread.

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.

Some people were prescribed 'as required' (PRN) medicines. PRN protocols were not always in place, and when they were in place, they lacked detail and personalised information. Guidance was not available to support staff with variable dosing. This increased the risk of people not receiving their medicines in the most effective way.

Some people were prescribed creams to alleviate skin conditions. Guidance was not available to show where on the body creams needed to be applied. Staff provided conflicting feedback about where they would apply creams. Cream containers did not always have opening or use by dates. This meant we could not be assured creams would be effective.

Some people had been prescribed medicines which were subject to extra controls. Records demonstrated staff were not following guidance from the National Institute of Clinical Excellence (NICE) to ensure safe practice. Our observations corroborated this. This increased the risk of harm to people.

Stock ordering processes were not effective. There was evidence of medicines not being available when people needed them.

Medicines audits were carried out, but these were not effective in identifying the issues found at the time of the inspection.