Kings 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 regulation in relation to safe care and treatment. We found some shortfalls in medicine storage, understanding of infection prevention and control and inconsistent record keeping.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

Where accidents and incidents occurred, these were recorded and reviewed by management and then a monthly analysis completed to look for themes, trends and lessons learnt. As a result of 1 person receiving an injury to their foot due to bed rails being in situ, it was decided to assess everyone using bedrails to have bumpers fitted to them to reduce the risk of similar incidents. Other people were referred to external healthcare professionals for assessment or to provide equipment to reduce the risk of further incidents. A staff member said, “If someone had a fall, while waiting for the ambulance we would check all the body, do vitals checks and check they are okay and comfortable. We also have to a report if anyone falls, email to management and then the deputy and registered manager would discuss with us. We share information.”

Staff 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.

Staff told us the deputy manager would visit a person to carry out an assessment prior to them moving into the service. This helped ensure Kings Lodge would be the most suitable place for the person to live and that staff could meet their needs.

The deputy manager told us, “Previously we would do assessments over the telephone, but at times we could end up with conflicting information, so we prefer to go out and meet the person. On our care planning system we have access to GP Connect. This enables us to see a person’s medical history which really helps with our assessment. We aim to have the person’s care plan set up within a week.”

They went on to say, “We had a situation recently where we were told a person had a particular dressing for a wound and that a referral to the Tissue Viability Nurse had been made. After visiting the person and following this up with the hospital, we found this was not the case. It enabled us then to ensure we had the appropriate dressings in place and do the referral prior to the person moving in.” A relative told us, “[Staff name] went absolutely above and beyond and helped him settle in.” Another said, “It’s been quite a journey. They (staff) have worked around him.”

Staff worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that. Staff shared concerns quickly and appropriately.

Staff had undertaken safeguarding training and put this training into practice. For example, 1 staff member said, “One of my residents I saw redness/bruise. I took a picture, informed and report to unit manager and the nurse after that.” We reviewed information around allegations of abuse, or incidents that were of a safeguarding nature and found the service had notified CQC in relation to these as well as to the relevant safeguarding authority.

We checked whether the service was working within the principles of the Mental Capacity Act 2005 (MCA), and whether any conditions on authorisations to deprive a person of their liberty had the appropriate legal authority and were being met. We found mixed evidence of the Act being followed properly.

One person who had capacity moved into the service; however, staff made a best interests decision with the family for the person to live on a key-coded unit, despite the person not wishing to do so. A family member told us, “I just want her out of here. She shouldn’t be on that unit,” and a staff member said the person had “escaped” from another unit and was therefore placed behind a locked door. The registered manager told us the person knew the door code and had been offered accommodation elsewhere in the service, which they declined, although this was not evidenced or confirmed by the person. As such, living on a locked unit could be viewed as a restrictive practice; however, the impact on the person was considered low as alternative arrangements appeared to have been offered, despite a lack of documented evidence of discussion with the person.

Staff had however followed the MCA principles for other people as individual decisions had been assessed and best interests decisions made in relation to people with bed rails or for living at Kings Lodge.

Staff did not always work well with people to understand and manage risks. People’s care plans were not always clear, and staff did not always record information consistently about people.

In 1 person’s care plan it stated their blood sugar should be checked 30 minutes after breakfast, lunch and dinner and yet, upon review of their care notes, we found this was being done frequently before breakfast and their evening meal and additionally not always within 30 minutes.

We found bowel monitoring was not consistently recorded for people at risk of constipation. Records showed gaps across several dates for at least 3 people despite their care plans stating bowel movements must be accurately monitored and action taken if constipation occurred. The registered manager told us this issue had been identified through audits; however, our review of the audits showed that they did not consistently identify instances where people’s bowel movements were irregular, absent, or not recorded correctly. Although there was a potential risk that some people may not receive appropriate treatment to prevent constipation, the immediate impact on people was low, as management were now aware of the issue and were taking steps to address this.

We were also told that people went into other people’s rooms. One person said, “I keep my door locked, because people kept coming in.” We read of incidents where people were found in rooms that were not theirs. This meant that distress may be caused to people and their privacy may be violated.

Other people’s risks were monitored, however, and action was taken to prevent them from being harmed. This included where other people had diabetes, and their blood sugar levels were being taken and checked appropriately and where people were at risk of choking and their food was modified to an appropriate consistency in line with Speech and Language Therapy guidelines. We also observed a staff member competently distracting and reassuring someone to reduce the risk of their anxiety overwhelming them. A relative told us, “I have no qualms about leaving here. I go on holiday and don’t worry.” Another said, “I can sleep well at night and have actually allowed myself a few days off (from visiting).”

Staff did not always control potential risks in the care environment.

We found a large ‘ornament’ propping open 1 person’s bedroom door which had been placed there by another person, meaning this person’s door would not have automatically closed if the fire alarm had been triggered. We alerted staff to the ornament as despite staff being around, they had not noticed this or removed it. Following our conversation with them, the ornament was removed.

Despite checks being undertaken on the building to ensure it was a safe place for people to live, we found the flushing through of the water (to test for Legionella) had not been carried out in October 2025. This meant a required safety check was not consistently happening.

Despite this, weekly fire alarm checks took place, together with other maintenance checks. Each person had a personal evacuation plan in place. We checked these against the list of people we had been provided with and found that all were present. A staff member told us, “We have a meeting point at the reception. The unit manager would go to reception, and everyone would check the alarm. I had fire training not long ago. Fire alarm tests are done every Wednesday.”

The registered manager had enough qualified, skilled and experienced staff in the service, but we heard, and our observations were that deployment of staff was not always well planned, particularly in 1 living area of the service.

Staffing levels were based on people’s individual dependency, which was assessed on the day of admission and regularly thereafter. The deputy manager told us the required staffing levels were always met, and the service had a “Good pool of bank staff” they could call upon if needed, rather than having to use agency staff.

We received mixed feedback from people, relatives and staff on the staffing, however. One person said, “I shout if I need staff. This works and I don’t have to wait long.” Another told us, “They (staff) don’t come in that often. Sometimes I feel as if I’ve been forgotten about, just left. Yesterday I didn’t get breakfast until 11:30 and then lunch is at 12.” Other people said, “It’s not always easy to get things done here” and “No one here as usual. Even getting a cup of tea is a (swear word) nightmare.” This person was told by a member of staff that they would get them a cup of tea, but after 15 minutes, they had still not received one. We also found some people without their call bells to hand. They both told us they would call out if they needed something. Leaving people to call out is not an acceptable alternative to ensuring essential equipment, such as a call bell, is available for people.

Relatives’ feedback included, “At times no (not enough staff). Look around now”, “With the amount of people and their needs, I don’t think so (enough staff). There have so many different needs, they (staff) are stretched”, “There could be more. This unit is difficult.” Other relatives told us that staff deployment was better than it used to be.

Staff told us, “One more carer would be helpful when we do personal care. We don’t have anyone to watch everyone. In the morning it’s impossible to offers showers every day. People go into each other’s rooms and take their stuff and that causes arguments” and “Sometimes it may be difficult.” However, others told us, “We have 3 staff. That is enough. Occasionally, we may be short-staffed, but others come in to help. We work well together, so we have a good routine and it works” and “We have time to spend with people.”

We were told, in 1 unit, that 2 people required 2 care staff to assist them with personal care and, “A lot can need 2 carers for personal care, it depends on the day” yet there were only 2 care staff and 1 care manager on this unit for the 15 people that required assistance. A staff member told us, “Every day we shower a couple (of people). There is like a (mental) rota and we work out when they (person) last had one. It would be a maximum of 3 days (without a shower).” A relative said, “They could do with an extra one (staff). She could be showering more.” This demonstrated to us that staff deployment needed to be reviewed across the whole service and in particular, in relation to certain times of the day. We have addressed this further in our key question of 'Well-led'.

Staff received training and supervision, although some staff said they felt they could do with more. Staff told us, “I would be confident knowing what to do should someone choke” and “I have done dementia care and first aid. I have been set up on the e-learning. I don’t mind learning more.” Other staff said, “I would like more training” and “I have not had dementia training. I have been asking for it at each supervision. I have learnt myself about people and what works.” Staff told us they had regular supervision which gave them the opportunity to meet with their line manager on a one-to-one basis.

We received positive feedback about the competency of staff and our observations supported this. One relative told us, “Staff seem to know how to operate the equipment.”

Staff were recruited through a thorough recruitment process, which included verifying their work experience, right to work in the UK, and suitability for the role. Staff underwent a Disclosure and Barring Service check which helped ensure they were suitable to work in this type of service.

Staff were not always aware of good infection control procedures.

During our observations of the environment, we found in 3 sluice rooms (rooms dedicated to cleaning soiled equipment) supplies of incontinence pads stacked on shelves out of their packets. This left them exposed to the atmosphere, dust or moisture, which increased the risk of infection, particularly for people who are vulnerable or have broken skin. In addition, we found dirty items stored in the ‘clean’ area of the sluice room, some of which still had faeces on them. We raised these concerns with the deputy manager and nominated individual during our inspection, and they reported following our visit that these had been addressed with the staff.

Some of the items of furniture at the service were worn or chipped, meaning the ability to clean them thoroughly would be reduced, and they created a risk for trapped bacteria. This included bedside tables in people’s rooms and a cabinet in a communal bathroom. We also found pockets of malodours in the service, particularly in 1 unit and 1 person’s bedroom.

Other areas of the service were clean and well-presented, and we observed housekeeping staff at work throughout the day. We also observed staff wearing appropriate personal protective equipment (PPE) when entering people’s rooms to provide personal care. One person told us, “They (staff) are very good at using PPE.” Relatives said, “It’s okay with the cleaning” and “Her room is clean and tidy.”

We found some areas of medicines processes were not robust, however, we did not have any concerns that people were not receiving their medicines safely.

On the day of inspection, we found that the storage of some medicines was not following best practice guidance. We found controlled drugs (medicines or substances that are regulated by law) stored in amongst day-to-day medicines in both clinical rooms we checked. We raised this with the deputy manager, and they took action to separate the controlled drugs from general medicines to improve the safety and security of those medicines.

We also found that the recording of medicines was not always correct. One person’s carry-forward medicine count said 6 tablets should remain, and yet there were 5 in the box. Another person had been prescribed 14 tablets of a medicine in July, and yet, their medicine administration record (MAR) incorrectly recorded zero, as the medicine count had not been updated on their medicine administration chart.

One person was being given Lorazepam regularly, and although guidance from the older people’s mental health team was in place to say they could administer this to reduce the impact of anxiety with personal care, staff were not recording in the daily notes why it was being given.

However, we found clinical rooms were clean and well-organised and large enough for easy movement of staff when transporting the medicines trollies. Temperatures of the room were checked daily, and staff were able to describe what they would do should the temperature exceed the recommended level. There was no evidence of excess stock of medicine and no medicines were out of date.

One person fed back, “My medicines are always given on time. [Staff member] always stays to make sure I’ve taken them.” Relatives told us, “He has to have his medicines covertly (without their knowledge) and they do this very well” and “[Staff member] even stays late sometimes after his shift has ended to make sure my father has his medication at night with someone he trusts.”