Archived: Durnsford 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 inadequate. At this assessment, the rating has remained inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was previously in breach of the legal regulation in relation to safe care and treatment and staffing. Not enough improvement had been made at this assessment, and the provider remained in breach of these regulations. In addition, we found the provider was in breach of legal regulations in relation to person-centred care.

This service scored 34 (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. They did not always listen to concerns about safety or fully investigate safety events. This meant there were missed opportunities to learn lessons and embed good practice.

The nominated individual and registered manager told us they used information from accidents and incidents to learn lessons. Outcomes were used to make service improvements and shared with the staff team via team meetings, as well as relatives and other healthcare professionals if appropriate. We found the provider had not developed a proactive and positive learning culture in which concerns about safety and quality were identified and responded to promptly and robustly. There was limited information to indicate the provider had learnt lessons from previous inspections or embedded good practice. For example, prior to this assessment [March 2025], the registered manager notified the Commission of 2 safety incidents. The first related to a person who had fallen out of bed between the bed and the wall, sustaining injuries to their face and body. The registered manager told us they had taken action to address ongoing safety concerns, such as replacing the bed, carrying out a bedrail risk assessment and installing bedrails to mitigate the risk of entrapment. However, we found the bed had not been replaced, there was no assessment of risk relating to the equipment or the environment, and learning from this event had not been applied to other people living at the service in a similar situation. The second related to a person who had left the service in the early hours of the morning and was found by a member of the public. The registered manager described the action they had taken, which included boarding up the front gate to prevent reoccurrences, all gaps in the fencing had been filled, and staff had been spoken with. When asked, the registered manager and nominated individual confirmed they had not looked at the wider safety concerns surrounding the security of the area at the front of the property following this incident. We noted this had been the second incident where a person living at the property had been able to access this area at the front of the property unsupported.

The provider’s failure to effectively operate systems to identify, assess and mitigate risks associated with the health, safety and welfare of people using the service placed people at an increased risk of avoidable harm. This contributed to a continued breach relating to safe care and treatment.

People who were able to share their views told us they felt safe. One person said, “I want to be in my own home, but I don’t feel unsafe here.” Relatives we spoke with did not raise specific concerns about people’s safety and told us the service kept them updated. One relative said, “They contacted me about an incident where they left [person’s name] in a wheelchair, and she developed redness, and the staff got told off.

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.

We found robust assessment processes were not in place to ensure a safe and smooth transition between services to reduce the risk of avoidable harm to people. Some care records lacked sufficiently detailed information and guidance for staff to ensure people received the health support they needed promptly.

Staff told us they read people’s care plans and spoke with people to understand how to meet their needs. However, we found care records did not include important information and guidance from assessments completed prior to people being admitted to the service. Care plans did not always contain accurate or sufficiently detailed information about people’s care needs or risks. For example, in relation to the management of epilepsy and diabetes care.

The provider’s failure to ensure staff undertook a pre-placement assessment meant they could not be assured they were able to meet people’s needs before they were admitted. This contributed to a breach of regulation in relation to safe care and treatment and person-centred care.

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. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect.

At the last assessment, we found the provider had failed to effectively establish and operate systems to investigate and report allegations of abuse and provide care and support in line with the Deprivation of Liberty Safeguards code of practice. This was a breach of regulation in relation to safeguarding. At this assessment, improvement had been made, and the provider was no longer in breach of this regulation. However, more improvements were still required.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this is usually through the Mental Capacity Act 2005 (MCA) application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found one person’s DoLS stated they were vulnerable and at risk if they were to leave Durnsford Lodge without staff support. However, we found this person was regularly able to use an unsecured area without staff support. We also noted this person had a restriction placed upon them without a legal framework in place to support this. Please see the effective section of this report, ‘Need for consent’, for more information. Following this assessment, the registered manager told us they had withdrawn the DoLS application with the local authority and were reviewing their use of restrictive practice.

The registered manager described how the service protected people from abuse, along with the action they would take should they be made aware of any concerns about people’s safety. All of which was underpinned by the service’s policies and procedures. Records showed where concerns had been raised, the provider had shared this information with the local authority.

Staff had received training in safeguarding adults. They were aware of their responsibilities and knew what action to take should they suspect a person’s safety or welfare was at risk. One member of staff said, “I would speak to the manager or contact the local authority.” Another said, “I have had training, I would report any concerns to the manager straight away.”

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.

At the last inspection, we found the provider had failed to assess and mitigate risks; this was a breach of regulation in relation to safe care and treatment. At this inspection, we found not enough improvement had been made, and the provider remained in breach.

We found the provider’s ongoing failure to take adequate steps to address concerns relating to the management and mitigation of risks meant people continued to be exposed to the risk of avoidable harm. For one person with epilepsy there was no epilepsy care plan or risk assessment in place to support staff in delivering effective epilepsy care. Staff told us and records confirmed the provider had not provided them with epilepsy training, and they were not sure of the action they should take should this person experience a seizure. Another person with insulin dependent Type 1 diabetes had no care plans or risk assessments to support staff in delivering effective diabetes care. The provider’s failure to ensure staff assessed and mitigated risks associated with providing care and treatment exposed people to an increased risk of avoidable harm.

Where risks had been identified, the provider had failed to take sufficient action to mitigate those risks and keep people safe. For example, an incident record for one person indicated at times of increased emotional distress, they may become verbally and physically aggressive towards other people living at the service. We reviewed this person’s care records and found there was no assessment of risk in relation to physical aggression or emotional distress. There was limited guidance for staff on how to identify and support this person to manage periods of emotional distress and reduce any associated risks to themselves and others.

The provider’s continued failure to ensure risks relating to the safety of people receiving care and treatment were appropriately assessed, mitigated, or effectively managed placed people at an increased risk of avoidable harm. This contributed to a continued breach of regulation in relation to safe care and treatment.

People seemed content and happy living at the service, while most people were not aware of their care plans or associated risk assessments. Two people told us staff had not involved them in the development of their care and support. One person said, “They [meaning staff] don’t particularly talk with me about my care plan.” Another said, “They asked me some questions, but I haven’t seen my care plan.”

Relatives did not raise any specific concerns about people’s safety. Comments included: “He [meaning relative] has not raised any concerns about the home, and he appears to be very happy there.” “No concerns at all, I am all praise for the place,” and “I have never expressed any concerns.”

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.

At the last inspection, we found the provider’s continued failure to ensure the premises were clean, suitable for the purpose for which they were being used and properly maintained was a continued breach of regulation in relation to premises and equipment.

At this inspection, we found some improvements had been made and the provider was no longer in breach of this regulation [premises and equipment]. However, we found more work was needed to ensure environmental and equipment safety concerns were addressed. For example, the door leading to the kitchen, laundry, staff room, and meds room had been tied open. The notice on the door stated, ‘Door to be closed properly at all times.’ Later that morning, we saw the maintenance person fixing a bedrail. Records showed, and staff confirmed both the door and bedrail had been broken since 18/04/2025, 6 days prior to our assessment.

The provider had installed a ramp to provide better access for people who may have greater mobility needs. We noted the ramp was a little steep and did not have a handrail. We discussed the installation with the provider, who was unaware of the need to follow the necessary regulations/guidance for the installation of accessibility ramps and the need for them to be installed at the required gradient. Following the assessment, the provider confirmed the ramp’s gradient was not in line with the guidance.

The provider’s continued failure to ensure there were suitable arrangements in place to address environmental and equipment safety concerns without delay placed people at an increased risk of avoidable harm. This information contributed to a continued breach of regulation in relation to safe care and treatment.

The provider had invested in the service and taken action to address many of the environmental concerns we had identified at the last inspection in April 2024. For example, we saw the provider had invested in new chairs and furniture, installed a new wet room on the top floor of the main building and fixed the toilet on the ground floor, all of which had a positive impact on people’s lives. The service had employed a maintenance person and developed a maintenance plan, which provided a clear view of what needed to be done and by when.

People who were able to share their views with us did not raise any concerns about their living environment. Relatives told us the service was clean and well-maintained. Comments included. “Yes, they are always making improvements and it’s maintained to a very high standard,” “Yes, I am quite impressed with the place, and I would go there myself,” and “It would appear to be tidy, clean and looks fine”.

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.

At the inspection in April 2024, we found the provider’s failure to ensure staff were recruited safely and to provide sufficient numbers of skilled staff to meet people's assessed needs was a breach of regulation in relation to staffing. At this inspection, we found not enough improvement had been made, and the provider remained in breach.

When we arrived at the service, there did not appear to be enough staff to meet people’s assessed needs safely. There were 2 care staff on shift providing care and support to 21 people. Care staff were responsible for providing personal care, assisting with breakfast, providing observations within communal areas and managing the laundry. A senior carer was in charge of the shift and was responsible for answering the phone and administering people’s medicines. The nominated individual was in the kitchen, and an administrator was in the office. A third care assistant arrived at 9 am, and a cleaner at 10 am. Throughout our site visits, we saw staff were constantly busy, moving from task to task and did not appear to have sufficient time to engage with people in a person-centred way; some areas of the service were not clean, there was insufficient management of laundry, and some maintenance issues had been outstanding for several days.

13 staff told us there were not enough staff to meet people’s needs safely and get everything done. Staff said they did not have time to do the laundry, provide any meaningful activities or provide adequate supervision. Senior staff told us that when the laundry assistant and deputy manager left, they had not been replaced. This meant care staff were having to pick up their duties. In addition, the registered manager had reduced care staffing in the morning.

We discussed staffing with the registered manager and nominated individual, who told us they used a dependency tool to determine staffing levels, which were sufficient to meet people’s assessed needs, and they did not believe the increased workload would have any impact on staff.

We reviewed the provider’s dependency tool and found this was not accurate as it did not appear to be in line with people’s assessed needs, nor did it consider staff breaks, the writing of care notes, laundry, or the provision of meaningful activities.

The provider monitored staff training on a training matrix. This showed staff had received training in a variety of subjects relevant to their role. However, we found, none of the staff had been provided with epilepsy training or end-of-life [palliative care] training. The provider’s failure to provide this training meant they were not able to demonstrate staff had the necessary skills, knowledge, or competence to meet people’s needs safely.

Training did not always determine staff practice. We continued to identify gaps in staff knowledge, which potentially placed people at an increased risk of avoidable harm or risked compromising people’s rights. For example, 4 staff members had received training in diabetes. However, when asked, none were able to describe the symptoms of high or low blood sugar. We noted the registered manager and nominated individual received enhanced mental capacity training; however, they had failed to ensure people’s basic rights were being upheld. [see consent to care and safeguarding sections of this report]

Records showed all staff completed an induction, which included practical guidance regarding the use of mobility equipment and an assessment of their competency prior to working with people. However, some staff told us they did not receive any specific practical training regarding the use of equipment or how to support people with their mobility as part of their induction and were unaware an assessment of their respective competencies had taken place.

Within the service, there was a list of ‘care champions.’ Within a care home setting, these roles are normally held by staff who have a passion for a particular area of care, acting as role models and promoting best practices. Staff confirmed no one had talked to them about what these roles meant, what was expected, and they had not been provided with any additional training or development.

Records showed staff were not receiving regular supervision. We reviewed the providers’ supervision matrix and found that some staff were not receiving regular supervision. For example, one member of staff had not received supervision since 25/01/2023.

The provider’s continued failure to deploy sufficient numbers of skilled staff to meet people's assessed needs, to ensure staff received the support, training, and professional development necessary for them to carry out their roles and responsibilities, placed people and staff at an increased risk of avoidable harm. This contributed to a continued breach of regulation in relation to staffing and safe care and treatment.

Most people who were able to share their views with us did not raise any concerns about staffing levels. However, one person said, “There were not enough staff on at mealtimes as so many people stay in their rooms and needed assistance. Relatives spoke positively about the levels of staff within the service. One relative said, “I would say yes, there are enough staff from what I can see.” Another said, “We have only visited during the day and there were a number of staff around, so my senses say yes.”

The provider did not always assess or manage the risk of infection.

The provider failed to ensure that people and staff were protected from the risk of infection, and best practice guidance was not always followed in relation to infection control, which placed people at an increased risk of catching and spreading infections. Poor infection control procedures and the lack of clear workflow systems to ensure the separation of clean and dirty laundry meant there was an increased risk of cross-infection.

We also found some aspects of the service were not clean. For example, we saw the lower floor wet room was unhygienic, and some people’s bedrooms contained an unpleasant odour and needed cleaning.

We were not assured all staff were using PPE effectively and safely. For example, throughout the first day of the inspection, we observed one staff member wearing blue gloves throughout their shift. This person was seen to enter multiple bedrooms and bathrooms whilst carrying out their duties. We did not observe this person changing their gloves regularly between tasks or interactions with people. We found the wearing of gloves in this instance did not prevent or reduce the risks associated with transmission and/or cross-contamination.

The provider’s failure to assess and mitigate risks associated with the management of people’s laundry and ensure staff followed best practice guidance in relation to infection prevention and control, placed people and staff at an increased risk of avoidable harm. This contributed to a breach of regulation in relation to safe care and treatment.

Other aspects of the service were clean.

Relatives did not raise concerns about the cleanliness of the service. Comments included, “Yes, very clean, no problems with cleanliness at all,” “Oh yes, very, I am always impressed with the home, it’s very clean and tidy,” and “Yes, the room is always well cleaned.”

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

At our last inspection, we found the provider failed to store and manage people’s medicines safely; this was a breach of regulation in relation to safe care and treatment. At this inspection, we found not enough improvement had been made, and the provider remained in breach.

The provider could not be assured people received their medicines as prescribed. We reviewed a selection of medicine administration records (MARs) and found one person had been prescribed medicine for pain relief when needed. Records indicated this person was receiving this medicine regularly. However, between 16 and 24 April 2025, staff had not offered this medicine as there was none in stock. We found, and senior staff confirmed, this medicine was in stock and available between these dates. This meant this person may have been exposed to the risk of unnecessary pain and suffering during this time. We further noted this person was prescribed medicine to reduce agitation. This medicine was available but not administered in line with the GPs’ prescribing instructions. The failure to ensure this person received their medicines as prescribed meant they were exposed to the risk of unnecessary suffering and anxiety. This contributed to a breach of regulation in relation to safe care and treatment.

At our last inspection, records relating to medicines requiring additional security were not accurate. At this inspection, we found improvements were still needed. For example, between January and April 2025, we found 36 recording errors, none of which had been identified through the provider’s audit system. This contributed to a breach of regulation in relation to good governance.

Following our last inspection, we found the provider had taken action to address safety concerns with regard to the safe storage of people’s medicines. Other medicines were administered safely. There were systems in place to audit medicine practice, and records were kept showing when medicines had been administered or refused. Staff told us they had received training in the safe administration of medicines.

People who were able to share their views with us and their relatives did not raise any concerns regarding their medicines. One relative said, “Yes, I do know, I go most days to see her and see her being given medication.” Another said, “When he needed medication, he gets it."