Haven 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 good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety.

This service scored 50 (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. We found a number of concerns at the service in relation to the completion of documents and management. No information about complaints had been recorded for over 5 years despite a member of the management team informing us recent complaints had been received, which meant there were no opportunities for learning. Staff reported they would raise concerns, and management would not listen or act when concerns were shared.

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. Some people had a considerable change of need which resulted in them presenting behaviours that challenge. This led to incidents involving other people in communal areas. These incidents were not recorded and reported to appropriate partners in a timely manner. However, since late June 2025 this had been addressed.

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. They did not always share concerns quickly and appropriately. Some people living at the service told us they felt scared; they described incidents of aggression involving another person in communal areas that left them feeling vulnerable and unsafe. We found the incidents had not been recorded, reported and shared with partners and no steps had been taken to protect people. However, since the recent management change, appropriate referrals and involvement from partners had been initiated and we saw evidence of ongoing support to actively improve people’s lives and protect them from further incidents. The service had a recently reviewed and updated their safeguarding policy.

The provider did not always work well with people to understand and manage risks. They 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. We found risks were evident in the service and although the provider was aware of the risks, they had not taken sufficient action to reduce and mitigate risks to people and staff. The provider did not have a restraint policy and staff were not adequately supported to manage incidents of behaviour and keep other people living at the service safe. However, since the recent management change, we saw evidence of involvement of partners offering support and guidance to the service, reporting and recording of incidents to relevant agencies to manage and mitigate risks.

The provider did not 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. The service had a maintenance person in post, and they told us they had completed checks. However, there was no evidence of any portable appliance testing (PAT testing). No safety checks of mattresses or profiling beds had been completed. Only 2 recorded recent fire drills were available and no other fire drills prior to the most recent completed at the service were available. The service did not have an asbestos survey in place. However, the acting and area manager had an action plan that had identified the issues with planned dates to ensure these actions were completed in the near future.

The provider did not always make sure staff received effective support, supervision and regular staff meetings. Staff did not feel empowered or listened to and felt concerns would be often dismissed. They were not encouraged to speak up and instead felt intimidated and isolated. They said the staff team had low morale and some staff worked better than others, but staff failings were not always addressed by leaders. Some staff reported improvements with the changes in management. All staff had a disclosure and barring service (DBS) check in place. However, 3 yearly updates had not been completed in line with the provider’s policy. Staff files did not always include identity documents, but this was being addressed. The provider made sure there were enough qualified, skilled and experienced staff and a dependency tool was used to assess staffing levels. The staffing numbers in place exceeded the staffing levels identified within the completed dependency tool.

The provider did not always assess or manage the risk of infection. Cleaning schedules were not in place. However, we found the environment to be odour free and generally clean and tidy. We observed staff bare below the elbow and wearing appropriate personal protective equipment (PPE). We saw evidence of regular domestics on shift completing tasks just no recording of completed tasks. On our second visit, the acting manager had introduced new cleaning schedules. The provider had recently reviewed their infection prevention and control policy to drive improvements.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were supported to manage their medicines. Clear medicine administration records were used to ensure an accurate record was being kept. Seniors completed regular checks of medicines. The provider had a recently reviewed their medicines policy.