Filsham 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. At our last assessment we rated this key question Requires Improvement. At this assessment the rating has remained the same.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was previously in breach of the legal regulation in relation to safe care and treatment. Improvements were not found at this assessment, and the provider remained in breach of this regulation. This includes medicine management, infection control and the management of risk regarding the maintenance of the building.

This service scored 47 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Learning from accidents and incidents whether positive or negative had not been recorded and shared with the staff team on a consistent basis. We were told that accidents and incidents were discussed at team meetings and learning shared. It was evident from the team minutes in May 2025 that recent safeguards were shared with staff. One safeguard completed in August 2025, reflected on the outcomes, for people, however interim actions to reduce risk or harm to individuals were not discussed. For example, 3 people had had between 3-7 falls in the month of May 2025 and these were not discussed at the June 2025 meeting, there had also been one choking event In May 2025, which was also not mentioned or reflected on. However, the July 2025 staff meeting was more detailed and had a section added ‘learning from incidents and safeguarding’.

A record was kept of accidents and incidents but lacked any analysis and plan of prevention for a re-occurrence. Some incidents and accidents had not been cross referenced into the persons care plan or risk assessment for staff to monitor. This resulted in a lack of preventative measures being put in place to maintain peoples’ health and well-being. Health and social care professionals had raised safeguarding investigations in relation to falls at the service and not all staff we spoke with were aware of this. However, the management team had also raised appropriate safeguards when required and sought advice from health professionals.

Staff did know the process to follow to report accidents and incidents and we saw forms had been completed. Relatives told us they were kept informed following a fall or any other incident involving their loved ones.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. However some assessments we viewed were not as thorough as others. Some lacked details of skin integrity and medical concerns.

Professional partners told us that not all transitions ran smoothly and that some admissions had been unsuitable for Filsham Lodge, this was currently being addressed by the local authority.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. People and relatives told us that staff were supportive and made the transitions they had to make between services run as smoothly as possible. One relative said, “The move went smoothly and she has all her bits that she can fit in her room.” Another relative said, “They moved from home. I had been looking after them and it was hard, here they ensured they settled and are so welcoming to me, it was a gentle move as possible.” Similarly, some people had hospital stays following accidents or illness. Staff advised that relevant sections from people’s care plans including known risks and health details were printed and sent with people when staying at other services

When people attended hospital appointments or transfer to a different service, a hospital passport is generated from their individual care plan and completed by the person in charge and sent with the person.

The registered manager tried to visit people face to face and completed a pre-admission assessment that ensured that the persons needs could be met by the skills of staff and premises.

Staff worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. However, communication between the staff at the service and health professionals had broken down, and this had the potential to impact on the outcomes for people and staff. The registered manager told us they were committed to improving people’s lives, while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

The provider investigated safeguarding incidents and shared concerns quickly and appropriately with the relevant authorities. Any outcomes were shared with the person and their family as appropriate.

Staff had received safeguarding training and were clear on how to report any concerns they had. One staff member told us, “I would report any concerns to the manager and expect them to deal with appropriately, I know we can contact the local authority and safeguarding team.”

There had been a high number of safeguarding referrals which were being investigated and therefore we cannot report on the outcomes and learning of these. Feedback from families during the inspection process was positive, one family member said, “They are really good here, they have involved me with all concerns as they happened, my loved one has deteriorated, he has also had problems with accepting care but they are so patient and got help.”

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS) The service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty. The documentation supported that each DoLS application was decision specific for that person. For example, regarding restrictive practices such as locked doors, covert medicine, sensor mats and bed rails. We saw that the conditions of the DoLS had been met. However we did see people restricted by a table to prevent them walking, and staff told us that holding a person’s arms during events when a person was distressed had helped the situation. These were fully discussed during the assessment process and action taken. Staff are to receive training on how to word interactions during an incident as when discussing how they managed distressed behaviour they said they hold on to their arms.

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

Effective systems were not always in place to assess, monitor and mitigate risks to people and keep them safe. We identified some people’s needs were at risk of not being met in respect of management of skin integrity, weight loss, behaviours that distress, choking, personal hygiene/oral hygiene. This was because not all documentation was up to date and reflective of recent events or accidents/incidents that impacted on their care needs. For example, some people’s weight charts evidenced that weight loss of between 9 kgs and 4 kgs in one month (June to July 2025). The monthly weight had been recorded on their care notes, but no action taken or queried. The registered manager told us that there seemed to be an issue with the scales but this was not explored within the records or their weight checked by an alternative method. This meant that staff could not be assured whether people were at risk from malnutrition.

Instructions regarding re-positioning for those at risk of pressure damage were not consistent. In one care plan it said 4 hourly repositioning whilst another part of the same care plan said 2 hourly as they had pressure damage.

Not all people that were at risk of choking had a completed risk assessment for actions to be taken or a care plan that guided staff in the prevention of choking. A recent episode had not been reflected in the person’s risk assessment or care plan.

Where people lived with a mental health diagnosis there was a lack of direction for staff of how to manage mental health changes. For example, care plans did not include up to date guidance for staff about triggers and de-escalation techniques for staff to use to help re-assure the person.

Daily records were not always consistent in documenting care delivery regarding behaviours that distress and oral hygiene.

There had been a high number of falls, whilst these are recorded, there was a lack of recorded actions or root core analysis to prevent a re-occurrence, such as checking walking aids or footwear.

There was some positive examples seen regarding management of risk, this included guidance and risk management of people on blood thinners, for people who were on continued bed rest and those who were at risk of infection. These contained sufficient information for staff to identify risk.

Staff received training in areas of potential risk such as moving and handling, first aid and health and safety. All staff had recently received fire training and undertook day evacuations to ensure all staff have confidence in the event of fire to manage people safely. A night evacuation had been planned. Personal Emergency Evacuation Plans (PEEPS) had been completed for each person. PEEPS give staff or the emergency services detailed instructions about the level of support a person would require in an emergency such as a fire evacuation.

Since the scalding incident the provider had taken steps to ensure that all risks relating to hot water and surfaces were managed. The registered manager checked temperatures daily and advised they would continue to so until the new maintenance team commenced work.

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.

There were areas of poor maintenance that had the potential to impact on people’s safety. These included corridor doors not working on the first floor which meant that people may be at risk from unsupervised access to stairs and fire safety concerns. When identified to the management, this was rectified within 24 hours. Extractor fans were not working in sluices and some ensuite bathrooms and this was to be addressed.

There was a shed in the rear garden that had broken glass, this was made safe during the assessment process. The lift on one unit had a piece of wood covering the safety glass which had been broken when the lift broke down. There were radiators with sharp corners in place which were not covered, and so could cause injury. These were covered during the assessment process.

There had been a recent fire inspection and the provider had been given time frames for essential work to be done by September 2025. We were assured that this would be completed within the time frames given.

There were maintenance issues found in most bedrooms and bathrooms where some work had been undertaken and was not completed. The provider and registered manager are in the process of recruiting a maintenance team to address the shortfalls in maintaining a safe environment.

Health and safety checks had been undertaken to ensure safe management of utilities, food hygiene, hazardous substances, and moving and handling equipment. Premises risk assessments and health and safety assessments were reviewed on an annual basis, which included gas, electrical safety, legionella and fire equipment.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

The training matrix identified that not all staff had completed the training necessary to meet peoples’ needs at Filsham Lodge Nursing Home. For example, emergency first aid, managing distressed behaviour, oral hygiene, and the mental capacity act. We could see evidence however that training was ongoing and that staff were reminded at staff meetings that their training was due.

There were sufficient staff deployed to meet peoples’ health needs, owing to recent events agency staff were being used to fill gaps when permanent staff were unable to. There were three activity people employed, that covered 7 days a week. However, during the site visits it was noted that two were on annual leave and therefore only one activity person was delivering meaningful activities to 55 people. This meant some people were bored and some people who stayed in their room were isolated. One person said, “I do get bored, I feel no one wants to talk to me, I would like a key worker again.” On the third site visit, there was a more energised feel in the lounges and people were doing activities and sitting in friendship groups. Care staff were seen to join them and enjoy the chats.

Staff had been safely recruited and staff files contained all of the required documents for example, references, employment histories and Disclosure and Barring Service (DBS) records. DBS help employers make safe recruitment decisions. Staff told us they had an induction period where they carried out initial training and were given opportunities to shadow more experienced staff.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The provider did not have robust quality assurance processes in place to promote sufficient infection control and had not identified the cleanliness issues found during this inspection.

The premises were not adequately clean, there was evidence of a build-up of grime on wheels of equipment, around toilets and the sluices smelt offensive and were grubby and disorganised. Commode pots were stained and unclean, as were urinal bottles and bins were in use without a lid and contained clinical waste. Assistance handles in bathrooms were rusted and nonpermeable and were a potential cross infection risk. Black mould was seen in corners of wet rooms, and drain covers were unclean. Some furniture that was in use had coverings that were damaged and therefore not able to be cleaned effectively and was a potential source of cross infection.

The overall cleanliness of the home was difficult for the housekeepers to manage as parts of the building needed repair and renewal. This included carpets, furniture and floor coverings. Bedrail bumpers were not clean, and some had cracked plastic coating which meant they couldn’t be cleaned properly. We were told that the bedrail covers were put in the washing once a week which may have contributed to the weakening/cracking of outer membrane.

There was an infection prevention control (IPC) policy in place. The registered manager was clear on the IPC procedures required and their responsibility to provide personal protective equipment (PPE). Good practice was observed with staff donning PPE at appropriate times when entering people’s rooms to carry out certain tasks.

On the third site visit we saw that an external contractor had addressed some of the identified issues.

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.

Not everyone could share their experiences regarding medicines, but one person said, “I get all my medicines, I see a doctor as well.” One family member we spoke with said, “Staff tell me when changes are made to my loved one’s medicines especially lately because they have deteriorated.”

Not all PRN (as required) medicines had protocols in place to advise staff when and how to administer PRN medicines. This was related to pain relieving and anxiety relieving medicine. No pain chart or agitation charts were in place. This meant people were at risk of not receiving medicines when they needed them, as documents did not detail signs for staff to look out for to indicate these were needed. There was also no directions for staff to use distraction techniques before administering anti-anxiety medicines.

There were two clinical rooms, both were in need of repair regarding locks and storage. One was cluttered and disorganised, the room temperature was not being recorded and therefore the storage of creams and medicines was not being monitored as per recommended guidance to ensure they were safe to use. There were free standing oxygen bottles incorrectly stored, and the dressing trolley had tubs of cream opened with no name of person on, indicating communal use, on opening it was discoloured and immediately discarded. In bedrooms we found that people had creams prescribed for other persons use. These were removed.

We were not assured that the principles of covert (hidden) medicine administration were being followed. This was fully discussed, and further training was to be introduced.

A recent visit by the Medicines Optimisation for Care Homes (MOCH) has made recommendations regarding systems for ordering of medicines and these were being set up with the health professional involved in the prescribing and dispensing of medicines.

Staff had received training in medicines management, administration and had access to the provider’s policy and their competency had been assessed.

Risk assessments were in place for certain medicines. The service use the EMAR (Electronic Medication Administration Record) All discrepancies and medicine errors were recorded and investigated and action taken as required