The Old Red Lion

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 outstanding.

This meant people were protected by a strong and distinctive approach to safeguarding, including positive risk-taking to maximise their control over their lives. People were fully involved, and the provider was open and transparent when things went wrong.

This service scored 94 (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 demonstrated an exceptional learning culture, where safety was prioritised through openness, professional curiosity and transparency. Staff operated within a no-blame culture, which enabled concerns to be raised and explored without hesitation. This resulted in safety issues being resolved swiftly and learning being shared across the service.

Staff consistently thought creatively about monitoring and evaluating safety, adapting approaches based on real‑time learning and reflective practice. They routinely sought continuous feedback from people, relatives, advocates and staff, not only in response to incidents but proactively as part of normal practice. This meant improvements were embedded early, and people benefitted from increasingly safe and well‑coordinated care.
People experienced fewer incidents, increased trust in staff, and greater involvement in shaping their own safety. Because staff acted on feedback immediately and transparently, people felt reassured that their safety was taken seriously and that their voices genuinely influenced their care.

The provider consistently ensured safe, reliable systems of care, working in close partnership with healthcare professionals to maintain safety across all pathways and transitions. Risks were anticipated rather than reacted to, and processes were adapted to suit each person’s communication, health and emotional needs.

A communication passport was used whenever people attended hospital, ensuring hospital teams understood how best to support and communicate with them. This reduced distress, improved clinical decision‑making and prevented avoidable harm.

Staff also recognised that several people had significant anxiety around services such as GP surgeries, dentists and hospitals. Staff went above and beyond, incorporating visits to these settings into community outings to build familiarity and reduce fear. When exposure was not possible, the service actively sourced and funded medical professionals to visit the home, ensuring people’s health needs were met without compromising their wellbeing. People accessed healthcare more confidently, missed fewer essential appointments, and experienced improved health outcomes. Anxiety about clinical settings reduced, leading to better engagement with treatment and earlier intervention for health concerns.

Safeguarding approaches were highly personalised and exceptionally responsive to each person’s definition of feeling safe. The registered manager and management team ensured safeguarding practice was grounded in peoples lived experiences, preferences and past trauma. This resulted in choice‑led, bespoke risk assessments that actively balanced positive risk‑taking with protection from harm.

Staff incorporated people’s individual histories into care planning, ensuring safety plans promoted independence, emotional security and personal growth. Adjustments were thoughtfully designed so people could pursue their goals confidently while remaining safe.
People developed greater autonomy, emotional resilience and trust in the staff supporting them. They were empowered to take positive risks, resulting in improved quality of life, increased community engagement and a strong sense of personal safety and control.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes 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. The Registered Manager demonstrated strong oversight of safeguarding and worked within the principles of the MCA. We found that issues were identified quickly and, staff followed the organisation’s procedures correctly and informed the registered manager without delay. They assessed concerns promptly, took proportionate action based on level of risk, and made timely referrals to the relevant external agencies, including the local authority safeguarding team, health professionals, and the Care Quality Commission. Lessons learned were shared with staff, which strengthened the service’s safeguarding culture.

During the assessment, we found the provider consistently demonstrated an exceptionally person‑centred and collaborative approach to understanding and managing risks. Staff worked holistically with people, ensuring support was safe, enabling and centred around what mattered most to each individual. This reflected the broader principle that people should be supported to understand and manage risks in a way that balances safety with independence and personal goals.

People were always treated as individuals. No positive risk was ever discounted, and staff used creative, strengths‑based thinking to help people pursue meaningful aims and wishes. Each person had a trusted relationship with a keyworker, which gave them consistency, emotional security, and the confidence to explore new challenges at a manageable pace.

Keyworkers supported people by breaking larger goals into small, achievable steps. This allowed staff to focus on one risk at a time, helping people gradually build skills and confidence. As a result, people reached milestones that previously felt unattainable, such as taking part in new community activities, developing independent living skills, or reconnecting with family routines.

Risks were reviewed weekly and monthly with people, ensuring plans stayed current and reflected changes in ability, comfort and motivation. This ongoing partnership meant people maintained ownership of their progress and had clear opportunities to reflect on what was going well and what they wanted to try next.

Families told us they felt actively included and supported throughout this process. They described being involved during visits and when people spent time on home leave, which strengthened consistency between home and the service which helped families feel confident in the approach to risk.

This outstanding practice resulted in people experiencing greater autonomy, increased emotional resilience, improved wellbeing, and a stronger sense of control over their lives. Staff consistently enabled people to take safe, meaningful risks that enriched their daily experiences.

The provider detected and controlled environmental risks and ensured equipment, facilities and technology supported the delivery of safe care. Where needed the provider went above and beyond to ensure peoples need were met and they felt safe in their environment. For example, where one person had a known trigger causing distress and damage if items were on the bedroom walls, the provider went above and beyond and installed false walls so essential fixtures such as radiators remained available without visual impact. People experienced fewer incidents, reduced distress and greater control over their space, which increased their sense of safety.

Some people living at The Old Red Lion struggled to regulate body temperature, the provider funded and maintained air‑conditioning, including discreet ceiling‑embedded units for those who did not want anything on their walls. People experienced improved comfort, better sleep and participation in daytime activities, which supported overall wellbeing.

These tailored environmental adaptations mitigated both physical and psychological risk, ensured sustained comfort, and meant people could live in surroundings that truly reflected their preferences and needs.

The provider made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. They worked together well to provide safe care that met people’s individual needs.

The provider had safe, robust and values‑based recruitment resulted in long‑tenured staff who knew people well, strengthening trust and reducing anxiety. People received consistent, personalised care from staff who understood their histories, communication and preferences.

Staffing levels and deployment enabled daily activities for every person, with staff flexed to meet changing needs. People benefitted from greater community access, improved mood and emotional wellbeing, and enhanced confidence in staff support.

Strategic workforce planning meant rotas were stable, responsive and resilient to unplanned absence, including on‑site sleeping and bathing facilities to maintain safe cover without disrupting people’s routines. People experienced continuity of care and uninterrupted therapeutic routines.

The staff team had a strong skill mix aligned to people’s needs and the provider delivered training beyond mandatory, including condition‑specific learning and staff wellbeing training. Competence was reinforced through frequent, reflective supervision and empowered shift leadership by team leaders. People were supported by confident, knowledgeable staff, which increased safety and improved engagement with health interventions.

The provider always effectively assessed and managed infection risks, ensuring people were protected as much as possible from the spread of infection.

People’s rooms were deep‑cleaned weekly while they were on home leave, including the use of an ozone machine to reduce odours. This approach meant bedrooms could be cleaned thoroughly without disrupting people or causing unnecessary stress, supporting both hygiene and emotional wellbeing.

Staff clearly understood their IPC responsibilities and consistently followed safe practices such as good hand hygiene, correct use of PPE, and adherence to appropriate cleaning routines. Records showed that infections were closely monitored, and any patterns or emerging risks were escalated for further investigation. This enabled the service to take early action to minimise the likelihood of outbreaks.

The provider successfully integrated IPC measures without compromising the homely environment. Cleaning products and PPE were stored discreetly yet remained accessible to staff when needed. Communal areas remained clean and hygienic while still warm, personalised and comfortable. People’s bedrooms retained their individuality and personal belongings whilst maintaining high cleanliness standards.

As a result, people lived in an environment that felt both safe and homely, with effective infection control in place that respected their comfort, dignity and preferences.

People were given their medicines safely and in a timely manner. This was recorded on their medicines administration record (MAR) and medicines were stored safely and securely. There were processes in place to ensure the safe and effective use of medicines.

The service had individual fire risk assessments in place for people who were prescribed paraffin-based skin products. Detailed guidance specific to each person on how to administer medicines prescribed as and when people required them, known as “PRN” was available to staff. Some medicines were prescribed with a variable dose i.e. one or two tablets to be given when required at regular intervals. The quantity given had been recorded, meaning records accurately reflected the treatment people had received.

The quantity of medicines was recorded upon receipt and then balances were checked regularly. We checked the quantities and stock balances for each resident and found them all to be correct. This meant that we could be assured that the correct doses of medicines had been administered as signed for by staff. The use of topical creams and ointments were recorded on the medicines administration records (MARs). Body maps were in place to show staff the site of application. There were appropriate arrangements in place for the management of controlled drugs. Records showed that staff completed regular balance checks in accordance with national guidance.

Temperature records to ensure the safe storage of medicines were completed in accordance with national guidance. This meant we could be assured that medicines were safe for use. Records were completed to reflect the name and quantity of medicines taken on offsite visits. There was evidence that there was a process in place to record medicines related incidents or errors. Records showed that staff had received medicines handling training. Staff competencies were assessed regularly to make sure they had the necessary skills. Managers and members of staff qualified to handle medicines regularly completed audits (checks) to make sure that procedures were followed.