Archived: Sonia Lodge

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment the rating has changed to Inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

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

This service scored 25 (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 make sure people’s care and treatment was effective because they did not fully consider people’s health and support needs. People’s care needs were assessed. However, assessments were not always individualised and did not always lead to a clear and person-centred care plan for the person. For example, one relative told us their loved one had had a number of UTI’s (urinary tract infections). We asked the service how often the person had a UTI. However, staff could not provide this information. Everyone at the service had a risk assessment in place for UTI as a matter of course and it was not clear who was at increased risk.

Care plans were also inaccurate in places. For example, one person’s care plan stated they were to be weighed daily to manage risk. However, this was not done and the provider told us this was not part of the person’s risk management strategy.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

Staff had access to best practice tools such as those used to monitor people’s weight or skin integrity. However, there were areas where records were not kept up to date which meant these tools were not always being used effectively to plan peoples care. For example, where people were at risk from weight loss they were not always weighed regularly to identify if they had lost weight and if they were at risk from being underweight and needed a specialist referral. One person lost weight in March 2025, was not weighed in April. When they were weighed in May they’d lost a significant amount of weight. They were then not weighed again until September when we raised concerns about the lack of monitoring. The person had continued to lose weight.

Staff did not always work well across teams and services to support people. Communication between staff needed to be improved at times. For example, one person had disconnected their catheter twice during the night. There was no record of this having been shared with day staff, nothing was noted in the persons daily notes nor in the communication book. Staff during the day did not know to keep more of an eye on the person in case this occurred again. The person did disconnect their catheter and staff were not aware this had occurred until we raised concerns with them.

Staff had access to health professionals’ assessments of needs such as the speech and language teams’ guidance for people with prescribed modified texture diets. However, staff were not always following this guidance.

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives.

Staff told us they monitored people’s fluids when they were unwell. For example, if they had a UTI but not prior as part of preventing the risk of a UTI developing. People were offered drinks during the day. However, there was a lack of recording in regard to what people actually drunk to enable staff to identify when people were not drinking well and may be at risk of dehydration. Staff told us one person had just recovered from a UTI and therefore was no longer being monitored. We looked at their daily notes and saw some days where there was very little fluid intake recorded for example on one day they had recorded 2 or 3 cups of coffee in the morning. However, no drinks were recorded after 11:27am. On 01 September 2025 a heath care professional advised staff to encourage the person to drink. However, the next day the person was noted as having only drunk half a litre of fluid.

One relative also raised concerns about how quickly health concerns were identified responded to. They told us, “My relatives health concerns are not flagged up and responded to quickly, I have to chase them, and they don’t keep me informed.”

There was an activities coordinator at the service who did encourage people to participate in activities including exercise-based activities.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

There was a lack of monitoring regarding people’s care and support. How often people’s continence aids were checked and changed was not monitored. For example, one person was recorded as being supported with their toilet needs at 05:48am in the morning and then no further support until gone 2pm in the afternoon. Then no further support until just after 7pm. The day prior to this was also similar. This was of particular concern as the lounge smelt of urine and we could not be assured people were being supported to change their continence pads frequently.

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

Whilst staff understood they needed to offer people day to day choices people’s ability to consent to care and treatment was impacted by the poor overall standards of care. For example, people were offered a limited choice of snacks and not offered an alternative meal when they did not want what was served.

Best interest decisions had been recorded when people moved into the service where people could not consent to their care. Where relatives had power of attorney to make decisions on someone’s behalf this was noted in their care plan. However, one relative told us they were not kept informed enough or involved in decisions. They told us, “I am not involved in any decisions because it’s a news blank.”