Goodson Lodge Care Centre

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 changed to good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider had systems to reflect and learn from incidents and accidents. Staff used reflective practice to discuss and learn from what had happened and how things could be improved. Leaders used analysis to review risks and identify any patterns or trends.

Incidents from across all the provider’s services were shared with all staff. A ‘learning alert’ was produced and shared to identify any actions needed to prevent recurrence.

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. The provider had policies and procedures to share information with medical professionals when moving between services. Staff shared a summary care plan and any information about medicines. If people were admitted to hospital, dependent on when they were discharged, leaders completed a re-assessment of needs. This helped to make sure if any additional equipment or support was needed this could be in place prior to discharge.

Prior to this inspection there had been 1 incident whereby the incorrect information went with a person to hospital. Whilst there was no harm caused by the error on this occasion, the level of risk for this incident was high. The registered manager shared the learning for the staff from this incident and how they would prevent this happening again. A letter of apology was sent to the people and relatives involved.

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.

Staff received training on safeguarding and understood what needed to be reported to the local authority. One member of staff said, “I am 100% confident they [management] would deal with any safeguarding concerns.” The registered manager understood their responsibilities and had ensured safeguarding concerns had been reported and investigated where needed.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that where appropriate the provider had applied to the local authority for DoLS authorisations. Information on the status of applications, the expiry date for those that had been authorised and any conditions was recorded in people’s care plans. The registered manager also had a tracker, so they had an overview of this information.

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. Risks to people’s safety had been identified and recorded in their risk management plans. However, actions to reduce the risks were not always recorded in a timely way. For example, people at high risk of leaving the building needed frequent wellbeing checks so staff could monitor their whereabouts. Records demonstrated these checks had not been completed with the frequency that was assessed as required. For example, 1 person needed increased monitoring and their care records for 2 days in January 2026 demonstrated these checks were not completed on time. On some of these occasions staff had recorded the check was late as they were supporting other people. We also found for 1 person needing re-positioning to reduce the risk of pressure damage, some actions were not completed as per identified frequency. Staff had also recorded in this person’s records they were late as they were helping others. Whilst we did not find any harm to people, records demonstrated people did not always receive their planned care on time which increased risks of harm.

Leaders ensured risk management plans were reviewed regularly. Following any incidents such as falls, staff reviewed falls risk assessments to identify any further safety measures needed to reduce risks.

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

Handrails were installed throughout the service to support people’s balance and help reduce the risk of falls. We observed staff using equipment correctly and supporting people to move safely throughout the building. For example, we saw 1 staff member ensured a person’s feet were correctly positioned and secured in the wheelchair foot straps before moving them, helping to reduce the risk of adverse incidents.

External contractors were completing regular safety checks on premises and equipment. There were also various maintenance and safety checks being completed by maintenance staff. There was clear fire safety signage. A fire risk assessment had been completed and there was a business continuity plan which highlighted what to do in an emergency.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

We observed there were enough staff to meet people’s needs. Staff told us there was enough staff available. One staff member said, “We have enough staff, if someone calls in sick, we get cover from other team members. We don’t rush; we support people according to how they want to be supported.”

The registered manager told us they were fully recruited for staff and rarely used agency staff. This helped to ensure people had continuity of care. However, we received mixed feedback from people about staffing availability. Some people told us there were not enough staff around, but others said there were enough staff to meet their needs. One person told us they did not feel their call bell was answered in a timely way. We shared this feedback with the registered manager.

Staff had been recruited safely as pre-employment checks had been consistently completed. Staff had an induction when starting work and were provided with refresher training as needed. We did find some staff training for dementia was out of date. The registered manager outlined plans to increase training completion rates over the coming year, with a stronger focus on instructor‑led sessions rather than e‑learning.

We also found that regular supervisions and work‑based observations were not always recorded formally. The registered manager informed us that a programme was being developed to address this. Staff told us they had the training they needed for their roles and had been supported with supervision sessions. One member of staff said, “We have formal supervision every 6 months. It is useful if we have concerns or if we want things to change. We can go before 6 months if we want to.”

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.

We observed the service was clean and smelt fresh. There was a team of domestic staff who followed schedules to ensure the service was kept clean. Housekeeping staff were aware of the importance of keeping cleaning equipment secured and away from people to help prevent potential harm. During the inspection, staff were seen locking their cleaning trolleys when moving on to other household duties.

We saw communal hand sanitisers throughout the service and there was enough personal protective equipment (PPE) available. We observed staff using PPE appropriately within the service.

Staff received training on infection prevention and control (IPC), and monthly IPC audits were completed to monitor compliance.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We found that medicines administration records (MAR) were not always fully completed. For example, we saw that 3 records did not contain details of the quantity of medicines administered. Staff told us the provider required staff to count medicines daily and record the balance on the MAR. However, we saw 2 MARs which did not have a signed running balance. This meant there was not an accurate record of how much medicine should be in stock.

Some people had specific instructions for when to take their medicine, however these instructions were not always followed. For example, 1 person was prescribed a medicine which needed to be taken with or after food. However, this medicine was given 1 hour before the person ate which meant this was not in line with the prescriber’s instructions.

Guidance was available for staff detailing when medicines had been opened, and whey they should be disposed of. Staff we spoke with were able to describe which medicines were to be dated when opened and when they should be disposed of. We found 4 medicines, including eye drops, gels and nasal sprays that had not been dated when opened. We shared this feedback with the provider who told us they had identified this shortfall during their own medicines’ audits. Work was in progress to support staff to follow the provider’s policy.

The provider had a medicines policy including guidance for staff on the safe administration, storage and ordering of medicines. Staff had a good knowledge of the people they supported. We observed staff administering medicines to a person. The staff member clearly explained what the medicines were for, gave reassurance when required and followed good practice when preparing the medicine. Staff had completed training to administer medicines and their competency to do this had been assessed.

People we spoke with told us they were supported well with their medicines.