Harrier 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. 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 service was in breach of legal regulation in relation to people’s safe care and treatment and staffing.

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 service 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. The provider had systems in place to report, review and investigate accidents and incidents. However, these systems had not always been followed at the service. Incidents and accidents had been reported and reviewed with the staff involved. There was evidence of staff reflective practice and the reasons the incident may have happened such as an error on the electronic medicine system. There was some action taken such as staff having their medicines competency reassessed. But there was no evidence action had been taken to the risk factors staff had identified such as being distracted by people living in the dementia unit, while administering medicines. There was no evidence lessons had been learnt from the incidents.Following the inspection the provider told us they had implemented care bulletins for medication incidents where reflective colleague accounts have been completed to ensure learning was shared with the wider team.

Accidents had been recorded and reported as part of the registered managers monthly report for the provider. We reviewed 6 of these reports from March 2025 onwards; each month people had rolled out of bed several times for example in April 2025 there had been 19 rolls from bed recorded. Some people had rolled out of bed 9 times in a month, the reason for this had been identified as people’s bed rails being removed. There was no evidence people’s risk assessments had been reviewed to assess if people would be safer with bed rails in place.

Staff told us they were not always informed of changes as agency staff were often in charge of the unit and communication could be poor. Staff told us handovers were not always detailed, and agency staff did not always know where to record accidents or incidents.The provider told us all accident and incident reporting completed by staff both Care UK and agency staff were checked daily. However, the provider did not provide evidence of this.

The service 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. There were effective systems in place to assess people’s needs before they moved into the service. A member of the management team met with people before they moved into the service and completed a comprehensive pre-assessment. However, when people were admitted to the service staff told us they were not always given all the information they needed, especially when agency staff oversaw the unit.

The service did not always work well with people 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 registered manager had reviewed the use of bed rails within the service; the review had led to bed rails being removed from people’s beds. Where the bed rails had been removed people’s beds were lowered and safety mats put each side. Some people had rolled out of bed frequently; there had not been a review to assess if not having bed rails was appropriate for them. There was no evidence to show if people had been asked if they felt safe without bed rails. A person had asked for the bed rails to be put back even though they had not rolled out of bed, as they helped them to feel safe.

There were systems in place to report safeguarding concerns when they had been identified.Staff described how they would recognise signs of discrimination and abuse. They knew how to report concerns; however, some did not always feel confident to raise these with the registered manager. Staff told us they were not confident their concerns would always be taken seriously.

The registered manager had reported safeguarding concerns to the local safeguarding authority. However, they had not always acted to reduce the risk of them happening again. For example, when it had been reported staff were using poor moving and handling techniques, the registered manager had spoken with staff at a meeting and had undertaken supervision with some staff. However, they had not completed observations to assure themselves staff were moving people safely.

The service did not work well with people to understand and manage risks. Potential individual risks to people’s health and welfare had not always been assessed and there was not always guidance in place for staff to mitigate risks. When bedrails had been removed, action was taken to put in place safety mats and the beds were lowered to reduce the risk of injury if people fell out of bed. However, the risks to people and staff because of this change had not been considered. There was no guidance for staff about how to support people when providing personal care, for example, at what height the bed should be or if bedrails should be raised during care. Some people received all their care in bed; there was no guidance for staff about how to support them safely with large mats at the bedside or the bed being low in height. For example, bedside tables had to be placed on top of the mats, so people could reach items such as their drinks. The tables we observed being used in this way were unsteady. There was a risk the table would topple over causing drinks to spill on the person including hot drinks such as tea. Some people had rolled out of bed frequently; there was no guidance for staff about how to support people to get back into bed. For example, how to position the hoist under the large mat, as the legs may not be long enough to keep the hoist stable when trying to reach the person or place them under the mat with the person in place. People’s care plans and risk assessments did not contain detailed guidance about how to position the loops on people’s hoist slings to position them safely. This put people and staff at risk of potential harm.

A person who was living with epilepsy; had not had a seizure since living at the service, but they still had an active diagnosis of epilepsy. There was no guidance in place for staff to help them recognise if they were experiencing a seizure such as rigidity of their arms and legs or how they may present when recovering such as being sleepy. This was important when people’s general condition was deteriorating and may not be able to take their medicines regularly. We discussed this with the deputy manager during our assessment, and they changed the care plan immediately.

There were people who communicated their distress non-verbally with actions. There was limited guidance for staff about what were triggers for the person or how to de-escalate situations. Some people had urinary catheters in place to drain urine from their bladder, the guidance stated to change the drainage bag weekly but did not always include on what day or where to record the change. There was a potential risk the drainage bags would not be changed.Following the assessment the provider sent us completed records of weekly catheter bag changes.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider completed checks on the building and equipment people used to make sure they were safe. There was a maintenance team at the service, who completed remedial work and checks on the fire system.

However, the signs around the service did not support the needs of people with dementia. Signs for communal areas were not pictorial to help people recognise where rooms were such as lounges or bathrooms.

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. There had been a significant turnover of staff since January 2025 following a change of registered manager, 14 long term staff had left the service. Before our assessment we had received information from staff anonymously and relatives about the high use of agency staff which they felt placed people at risk. We reviewed staff duty rotas; these confirmed a very high use of agency staff including 2 night shifts where 80% of the staff were agency and there were no permanent team leaders or nursing staff in the service.During our first day onsite, 3 out of 4 units within the service were being led by bank or agency staff. Staff told us agency staff had often not been to the service before placing extra pressure on them, we observed this on our second day at the service. We discussed this with the registered manager who stated they were unaware there had been occasions where there were no permanent senior staff on duty. However, they had provided the staff duty rotas to the inspector.

Staff told us they were not always enough staff to support people safely especially on the nursing units where people required 2 staff to support them. They described occasions when there were 2 care staff working on the unit, they were unable to answer call bells until they had finished supporting the people they were with. Staff told us they often did not take all the breaks they were entitled to when they were working with agency staff or there were 2 care staff, as they were worried people would not be supported safely. A person told us, “There’s a lot of agency people and they’re not regular here. It’s always someone different so they don’t know me as well as the permanent staff. It means you must wait sometimes if they’re busy.” Relatives told us, their family member had often had to wait for support as staff were busy or unsure of how to provide the support needed. A relative stated, “There are never enough, not now. There used to be.”

The provider had an induction in place for new staff to cover all aspects of their role including moving and handling, infection control and safeguarding. However, staff told us they were not always supported following their induction. Staff gave us examples of being left in charge of a unit on their second day with agency staff who could not support them to use the electronic systems or support to know people well. Staff told us new staff had started, but had not always stayed, staff had described their frustration at not having the time to support new staff. Staff had not always received regular supervision. Some staff had not received supervision since April 2025.Following the assessment the provider told us they have now recruited to 100% of carers required including sickness and annual leave.

The provider did not always assess or manage the risk of infection. There were audit systems in place to monitor infection control, these had been completed monthly. Some shortfalls had been identified such as mobility slings not being washed as required, mattresses not being cleaned weekly and staff wearing acrylic nails.

Action had been taken to address the shortfalls, housekeeping staff confirmed they collected the mobility slings and slide sheets for washing. However, during our onsite visits a staff member continued to wear acrylic nails against the provider’s infection control policy.

The service was clean and odour free, there were separate areas for clean and dirty laundry. Communal areas and people’s rooms were clean and clutter free.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. There were systems in place to check staff medication competency, however, agency staff were often responsible for medicine administration. The deputy and unit manager completed monthly medicine audits, these had identified shortfalls each month, since February 2025 compliance had been below 90% and in May 2025 it was under 70%. The action plans put in place had led to improvements but with a variety of staff administering the medicines some issues continued. For example, people were not always receiving their time sensitive medicines to relieve their Parkinson’s symptoms when prescribed. The action plan stated this would be highlighted to agency staff, there had been some improvement, but the error continued. There had been other occasions where medicine dosage errors had been made, and these had been addressed with staff. A person told us, they received their medicines on time “most of the time.”

There were effective systems in place to order, store and dispose of medicines. We reviewed the electronic recording system, and the stock count was correct.