Worsley 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. There was an increased risk that people could be harmed.

The service was in breach of legal regulations in relation to staffing.

This service scored 62 (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 a proactive learning culture in relation to safety. There was a clear emphasis on openness, honesty, and continuous improvement. Staff were encouraged to raise concerns and report safety incidents, which were taken seriously and responded to appropriately. Incidents were investigated, and learning was identified, shared, and used to improve practice and reduce the likelihood of recurrence.

We saw evidence of a learning approach, where safeguarding outcomes and lessons learnt were documented and communicated to staff through team meetings. This supported shared learning and promoted safer practice across the service. Supervision processes reinforced this, with staff given opportunities to reflect on incidents and implement actions such as further training or changes in practice.

Staff told us they felt confident to report safeguarding concerns and that incidents were discussed openly, with a focus on learning. This demonstrated a strong commitment to improving safety outcomes and embedding learning throughout the service.

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.

Management and staff worked collaboratively with individuals and the wider healthcare professionals involved in their care. Concerns, such as swallowing difficulties or unplanned weight loss, were escalated promptly, and staff engaged effectively with speech and language therapists (SALT), GPs, district nurses, and other relevant professionals. Evidence demonstrated that the service worked closely with multidisciplinary teams and family members as part of the assessment process.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Safeguarding and DoLS notifications were well managed, the provider raised concerns promptly and in an appropriate manner. Staff had received safeguarding training and understood how to identify and respond to potential abuse. One staff member commented, “I would feel confident reporting any concerns. The manager would act and address anything brought to their attention.”

We reviewed whether the service was operating in line with the principles of the Mental Capacity Act (MCA), ensuring that correct legal authorisations were in place where individuals were deprived of their liberty, and that any related conditions were being followed. In cases where people were subject to such restrictions, referrals had been submitted to the local authority. The manager kept oversight of Deprivation of Liberty Safeguards (DoLS) applications, including any conditions linked to authorised DoLS.

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.

Staffdemonstrateda good understanding of people’s risks.Howeverthere was limited evidence todemonstratethat people and their families were meaningfully involved in decisions relating to risk management.We alsoidentifiedthat information within care records was not always clearly documented or consistentlymaintained.

In addition, discrepancies were noted within care plans. For example, one recordindicatedthat visits from an external healthcare professional had been placed on hold due to a decline in mobility. However,subsequententries from the same professional documented ongoing visits and progress being made.The provider told usduring this inspectionthat although there were occasional discrepanciestheyconsistently endeavoured toidentifyand resolve theseissues.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People and their relatives told us they felt safe living at the service.All systems and services within the home were wellmaintainedand regularly checked to ensure safety. We reviewed safety certificates for equipment, gas, and electrical systems, all of which met the required standards and weredeemedsafe for use.Regular audits and safety checks were being carried out tomaintaina secure environment. A fire risk assessment was in place, ensuring staff were able to effectively support peoplein the event ofan emergency.

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.

There were insufficient staffing levels during this inspection to meet the needs of people across both floors. We observed occasions where people with complex needs were left unattended in communal lounges, despite staff telling us that the service’s policy is that there should be at least 1 carer or senior there. Records showed that 2 hourly checks and repositioning moves for people that required it were often considerably delayed.

People and their relatives consistently told us that staffing levels were not adequate. They reported delays in receiving drinks, meals, and support with personal care. Comments included, “There’s not enough staff, the buzzer goes for ages, I can wait for over half an hour for a drink,” and “I’ve complained about the meals; it’s the service, sometimes they don’t serve people for ages and don’t give us a drink of tea.” There was a high reliance on agency staff due to vacancies and staff sickness.

Staff told us that staffing shortages had a negative impact on morale and service delivery. One member of staff said, “There is an issue with staffing here, there is not enough staff. It is busy and there is lots to do”. Due to staffing pressures, staff were primarily task focused. However, we did observe that interactions with people were kind and caring, and staff remained calm in their approach.

Staff completed a five-day induction when starting with the service, which included online training. We saw evidence that staff were recruited safely, with all relevant checks carried out, including a Disclosure and Barring Service (DBS) check. Records showed that staff were up to date with mandatory training.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was generally observed to be clean and tidy, however there was malodour and stained furniture in communal areas. Some peoples’ rooms had malodour and no bed linen. Bathrooms and smaller communal areas were maintained to an appropriate standard, appearing clean, orderly, and well-kept during the inspection.

Staff demonstrated an understanding of infection prevention and control procedures. They were observed using appropriate personal protective equipment (PPE) correctly and confirmed that PPE supplies were always readily available to them.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People’s medicines were managed, administered, and stored in a safe and effective manner. Systems and processes were in place to ensure that all medicines and treatments were handled appropriately and in line with best practice. Staff responsible for administering medicines had received the required training and had undergone competency assessments to confirm their ability to carry out these duties safely.

Electronic Medication Administration Records (EMAR) showed that individuals consistently received their medicines as prescribed. Body maps were also maintained and reviewed, evidencing the correct rotation of transdermal pain patches in accordance with guidance, helping to reduce the risk of skin irritation or reduced effectiveness.

Controlled drugs were managed securely, with records maintained in a dedicated controlled drugs register. Daily balance checks were completed to ensure accuracy and accountability, further supporting the safe management of these higher-risk medications.