Ormsby 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 inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of 4 legal regulations in relation to safeguarding service users from abuse and improper treatment, safe care and treatment; including management of risks, safe management of medicines, safe environments and infection control; staffing and fit and proper person employed.

This service scored 34 (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 have a proactive and positive culture of safety based on openness and honesty. They did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The provider failed to ensure that incidents and accidents were consistently identified, investigated and learned from. For example, most incidents related to escalated behaviours and anxieties, some of which involved physical altercations between people living at the service. However, there was no evidence to demonstrate that these safety events had been analysed to identify any themes, trends or ways to mitigate the risk of further occurrences. This meant some people remained vulnerable to repeated harm and inconsistent care responses.

Whilst staff demonstrated awareness of people’s individual needs, this insight was not supported by a culture of shared learning, limiting opportunities to improve practice and outcomes at a service-wide level.

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, including when people moved between different services.

For example,there were no formal referral pathways and no structured approach to assessing people’s needs at the point of moving into the service. The provider did not ensure that people had access to a welcome pack or service user guide which would help support them during this transition.

There was also no formal process in place for planning or supporting people’s transition out of the service, particularly for those who had lived there for a long time. This lack of structured discharge planning placed people at risk of experiencing unsafe and poorly coordinated transitions from the service.

Hospital passports were not consistently kept up to date, compromising the continuity of care during hospital stays or medical appointments. It is important to ensure essential information is shared between services as this helps ensure people receive continuity of care in a person-centred way.

While the provider had some contact with people and healthcare professionals, they failed to work in meaningful partnership to understand what being safe meant to individuals or how to achieve this. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

The service did not have consistently effective safeguarding systems in place. There were gaps in safeguarding and Mental Capacity Act (MCA) 2005 training. Managers did not consistently recognise their responsibilities to record and report incidents and safeguarding concerns, including medication errors. We reviewed multiple incident reports involving physical altercations between people living at the service, in several cases there was no evidence that post-incident welfare checks had been completed, meaning staff could not demonstrate that people’s wellbeing had been monitored and appropriate support given.

Blanket restrictions were in place, such as locked access to foods, sharps and toiletries, without supporting documentation, individual assessments or consent forms. Although leaders had recently started to revisit MCA processes, no assessments were in place for these restrictions, and the manager acknowledged gaps in consent records. These restrictions limited individual’s independence and autonomy.

A person’s risk assessment details that a person at risk of overeating or eating sugary foods should have the larder door locked at all times and although it states that the person will be supported by staff to access the larder, there is no supporting documentation that the person had been involved in this decision making or that this was the least restrictive option.

The provider’s safeguarding adult’s policy contained references to outdated legislation and did not reflect current best practice in safeguarding adults. The current policy risks misinterpretation and may result in safeguarding concerns not being escalated appropriately.

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.

Health related care plans were not always accurate or comprehensive. For example, a person’s insulin protocol specified administration for blood sugars over 20, yet this was not reflected in their care plan. This omission could lead to delays or errors in treatment, placing the person at risk of serious harm due to unmanaged high blood sugar levels.

Additionally, individuals using emollient creams did not have appropriate risk assessments and management plans in place, despite the serious fire risks associated with these products.

People’s risk assessments around community access did not include sufficient detail around how specific risks to that individual could be reduced.

People were not meaningfully involved in reviewing their risk assessments, meaning that plans lacked ownership, one person told us that they hadn’t used part of their plan for “ages” as it was out of date.

Risk assessments remained outdated for many years, often marked as “no change” at annual reviews, with some examples unchanged since 2004. Staff told us that where a risk assessment states that a person is supported by 2 staff, that this was not the case, and only one staff member was providing support. This put the person at risk because the risk assessment had not been updated to reflect their current needs, meaning care was being delivered based on outdated information, which could lead to unsafe or inappropriate support.

The provider and management team were not always clear of their responsibilities in relation to compliance with health and safety requirements. Systems and processes were not effective and failed to identify the concerns we found on this inspection.

Environmental risk assessments were either incomplete, outdated or failed to identify serious hazards. Window restrictors were found to be damaged or non-compliant, posing a potential safety risk to people. Risk related to unsecured or damaged furniture had not been fully assessed or mitigated. Some people exhibited known behaviours around tipping or throwing furniture. The lack of action to secure or replace broken furniture put people at increased risk of injury or coming to harm.

Hot pipework remained exposed and accessible, posing burn risks that were not mitigated. Outdoor areas contained trip hazards with no risk assessments in place. Personal Emergency Evacuation Plans (PEEPs) were outdated. Fire safety was compromised by obstructed or malfunctioning exits, missing or outdated fire audits, no recent fire drills, and irregular fire alarm testing. Legionella management was inadequate, with incomplete flushing records and no evidence of descaling. Outdated Control of Substances Hazardous to Health (COSHH) data sheets and missing radiator protection further exposed people to risks.

These failings placed people at significant, avoidable risk of harm, including injury, burns and delays in evacuation during emergencies, compromising people’s safety and wellbeing.

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.

The provider did not always ensure that staff were recruited safely and in line with guidance set out in regulation, and the policy did not contain accurate information on requirements. Required information set out under the 2014 Regulations was missing from staff files, including interview records, references or evidence of conduct in previous employment, health declarations. Staff files were incomplete or poorly maintained and did not include employment contracts. One staff member’s right-to-work documentation was found to be unclear or expired during this inspection. Although the manager took appropriate action to prevent their return to work until relevant assurances were sought, this had not been identified prior to the inspection, indicating a lack of effective oversight. This meant that the provider did not always take reasonable steps to assess new staff’s suitability for their role.

Staff had not received practical moving and handling training, or essential training in medicines, diabetes, and dysphagia, despite supporting people with specific health needs, including those at risk of choking and individuals living with diabetes. As a result, we could not be assured that staff has the necessary knowledge and skills to provide safe and effective care tailored to people’s individual health conditions.

There were significant gaps in oversight of staff performance, support and development. Regular one-to-one supervision was not in place, and no staff had received an appraisal in line with the providers own policy. This meant there were missed opportunities to monitor performance, identify training needs, and support staff development.

These shortfalls in training, supervision, recruitment, and performance management placed people at risk of avoidable harm. Staff were not consistently prepared, supported, or monitored to deliver safe and effective care.

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 Infection, prevention and control (IPC) risk assessment was outdated and did not reflect current risks or working practices. The annual IPC statement had not been reviewed or updated to include recent infectious disease outbreaks, such as chickenpox. There was no evidence that routine IPC or cleaning audits were being carried out.

The provider did not always follow effective infection, prevention and control practices. For example, record keeping in relation to infection control, cleaning and food hygiene was incomplete or inconsistently carried out. Cleaning schedules were completed as a tick-box exercise, with no system in place to verify the quality or effectiveness of cleaning. The ‘Safer Food, Better Business’ (SFBB) folder was incomplete, containing only fridge temperature logs and no documentation relating to cleaning procedures, cross-contamination prevention, or food safety controls.

The laundry area was visibly unclean, with rust present on washing machines, increasing the risk of contamination. Mops and cleaning equipment were stored in unhygienic conditions, and waste bins were not foot-operated, with several left open, creating a risk of cross-contamination. Additionally, there was no evidence that first aid boxes were routinely checked to ensure supplies were in date and available in an emergency.

These failings placed people at risk of avoidable harm by failing to maintain a clean, hygienic environment and by increasing the likelihood of infection transmission.

Some staff demonstrated a basic understanding of hand hygiene and used personal protective equipment (PPE).

The provider did not make sure that medicines and treatments were safe and met people’s needs, considered their capacity and preferences. People were not involved in planning how they were supported with medicines.

Medicines were not always safely managed within the service. Training records showed that staff had not completed medicines training or had their competency assessed. This increased the risk of medicines being given unsafely.

We were not provided with evidence to demonstrate that medicines audits were being carried out, so it was unclear whether regular checks were undertaken to support safe practice. There was a risk that medicines-related issues occurring in the service were not being identified. There was no evidence that medicines-related incidents were properly investigated or that actions were taken to prevent them happening again. We could not be assured that a good safety culture was in place.

The medicines policy did not reflect best practice in line with national guidance and lacked the detail needed to guide staff to administer medicines safely.

People’s care plans lacked clear information to help staff give medicines safely and in line with individual needs or preferences. For example, one person at risk of low blood sugar levels, had no planning in place for emergency medicines when out in the community. Another care plan had conflicting information about a person’s treatment for chest pain. It was not clear for staff to know how to manage their condition. When assessing if people could manage their own medicines, the assessments did not consider practical issues like memory or physical ability to open containers. This mean people were at risk of not receiving their medicines safely or effectively.

Medicines administration records lacked the required detail around how to safely administer people’s medicines. Doses for administration were not robustly and safely recorded on the administration records. One person’s insulin was recorded as ‘as directed’ with handwritten notes and ‘Post-it’ notes used for dosing instructions, their treatment for low blood sugar also lacked clear instructions. This meant there was a risk of medicine errors that could lead to serious harm.

Some people were prescribed 'as required' (PRN) medicines, which require clear protocols for their use. Guidance in the form of protocols or care plans were not always in place, adequately person centred or individualised to support staff in administration, this included medicines that were prescribed with a variable dose. For example, three people were prescribed pain relief with a variable dose of 1 or 2 tablets, however, there was insufficient information to support staff to determine when each different dose was required. There was insufficient recording as to why PRN medicines had been administered or if they had been effective. This information is required for monitoring the person’s needs and deciding if they needed reviewing by the doctor. This meant the provider could not be assured PRN medicines and variable dose medicines were always administered correctly.