Hawthorn Lodge Care Home

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 remained 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.

At our previous assessment, we identified breaches of regulation, in relation to dignity and respect, person-centred care and safe care and treatment. These breaches were reported on under Safe. At this assessment, we found the provider remained in breach of regulations related to safe care and treatment and person-centred care. We have reported on the breach of person-centred care under Responsive.

This service scored 47 (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 reviews of incidents to look for themes, lessons learned and inform improvements in care quality were not fully embedded. The times and locations of incidents or events were not being routinely used to inform care planning or staff deployment within the service. For example, where a person had exhibited distress behaviours, related to their district nurse advising bed rest; we saw the care plan for this person did not give guidance for staff on how to effectively support this person with understanding this temporary change.

The management team had worked hard to improve how issues were raised and responded to within the service since our last assessment. The management had changed, and we could see the improvements in the staff engagement and approach. Staff told us they now felt confident raising concerns with the manager and felt they would take action when they did so.

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.

Records showed that communication between the care home and external health and social care teams was improving; to ensure positive experiences and safe transition from other services. The new manager had made communicating effectively with people and their relatives a priority. They explained how they were aware of the challenges they faced to improve previous poor experiences in this regard.

We found people who required external review for their specific needs had been referred by the service when concerns had been identified or after a specific incident had taken place. For example, after sustaining an injury following a fall or when people had experienced a change in their cognition or behaviours. However, where reviews had taken place, this information had still not been fully updated across all people’s care plans or risk assessments. This left people exposed to the risk of staff not having clear guidance to ensure their support needs could be met.

Handover meetings within the staff team were used to identify where a person may require monitoring for a change in presentation. The daily handover meetings between staff shifts were attended and documented by the management team, to ensure any concerns were escalated.

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. The provider did not always share concerns quickly and appropriately.

There was an understanding of safeguarding and how to take appropriate action shown by the interim management team, but safeguarding had not always been given sufficient priority or applied consistently at Hawthorn Lodge. We found the previous management team had not always made timely notifications to the local authority safeguarding team or the CQC to ensure that incidents could be promptly investigated. The new management team were responsive when concerns were shared with them, and ensured referrals to the local authority were made in a timely manner.

People’s rights had not always been considered in line with the Mental Capacity Act 2025 and the Deprivation of Liberty Safeguards. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. However, records and further discussions with staff showed some people could not reliably understand how and why aspects of their care were being provided in the way it was. These decisions had not been assessed, recorded and reviewed in line with the MCA and best interests decision (BID) making. Whilst the management team provided some MCA assessments and BID making records following our assessment, these did not cover all specific decisions or include all relevant people.

Staff we spoke with showed increased confidence that the new management team would act appropriately if they raised safeguarding concerns. Staff were now confident in using whistleblowing processes if they felt concerns were not being responded to by the management team.

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.

Care plans and risk assessments had not been reviewed and updated in a timely manner to ensure risk was mitigated. The action plan submitted by the provider after our last assessment indicated this was a priority. However, we found the care records lacked evidence of review and completeness for some people. For example, one person had been advised by their district nurse to have a period of bed rest. The care plan and risk assessment for this did not guide staff on how to support the person when they exhibited distress due to not understanding this change.

The management team showed understanding towards people, and the staff team showed kindness when engaging with people. However, we found previous incidents had not been reviewed to ensure risk management was robust and people’s individual risk assessments were updated. For example, where people lived with behavioural support needs; Incidents between peers had not been reviewed or risks updated within people’s care plans.

People’s needs were not all clearly documented in their care plans, so staff lacked clear guidance on a person’s mental, physical and social needs. People’s communication needs were not all clearly documented. This left people at risk of staff not having a full understanding of their needs and wishes, to support them to stay safe.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The home was in a state of significant disrepair, meaning it was unsafe and unsanitary for people living there. Directional signage was challenging to read in corridors which had poor lighting.

Some areas of the premises placed people at risk of injury, particularly those who were independently mobile. Wardrobes were not always attached to walls, bathroom furniture was damaged, and the toilet basins, cisterns and sinks in bathrooms were poorly maintained.

Some windows were able to be opened wide, due to the frames and restrictors not being well maintained. This safety feature should prevent people from falling or climbing out in line with guidance from the health and safety executive (HSE).

The home was unsafe in the event of a fire. Fire doors, lighting, corridors and flooring were not well maintained or kept clear of any blockages, this meant people could not easily follow signage showing the fire evacuation escape routes. Regular fire evacuation drills had not been completed, to ensure the fire safety plan was robust.

We saw the kitchen was managed in a hygienic way by a knowledgeable member of staff, to ensure people were not at risk of food-borne infections. The most recent check from the food standards agency, had rated the service 5 stars on 11 December 2025. Staff had received food hygiene training; they were able to explain what actions they took to reduce the risk of food-borne infections.

The management team were responsive to the concerns raised by the inspection team. The service improvement plan was provided, which gave timescales for completion for the required actions. The management team shared regular updates with us on refurbishment measures and fire safety drills undertaken since our visit. However, this is the 10th consecutive inspection where the environment has been identified as not being suitable or safe for people. This left people exposed to the continued risks presented by a poor environment.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs.

Staff had received training and ongoing supervision to ensure they had the skills necessary to support all people’s identified needs. The service used a dependency tool to calculate the number of staff required for each shift. However, we found the service had insufficient staff available to support people. We observed that staff used their understanding of people as individuals to respond to people’s needs, rather than through effective care planning and deployment.

The majority of people we spoke with thought staff numbers were low, and expressed feeling unsafe, particularly at night. One person we spoke with said, “I’ve been here more than a year, and in the beginning if felt safe but it’s changed drastically now and you’re never sure how many carers will be on. They’re short. They only have two on at night and no-one seems in charge. I don’t like the staff at night as they don’t like being disturbed. They’re sharp with you.” Another person said, “They’re busier in the day and I’d say no, there’s not enough. And there’s no enthusiasm towards us. Only a few are very good at their job.” Another person told us, “They’re very busy. At weekends they use agency more and they don’t know the routines, or us.”

We raised these concerns shared by people with the management team, who responded promptly by reviewing their staffing levels. They allocated an extra member of staff for the night shift, carried out more frequent spot checks and updated their fire safety evacuation plan and personal emergency evacuation plans accordingly. The management team explained they had a number of staff on long term absence, which had increased the use of agency staff. This was an area which was under review by the provider.

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.

Good infection prevention and control practice was not being made a priority at Hawthorn Lodge. The provider had not considered the challenges that a poorly maintained environment had placed on the ability of the domestic team to ensure the service could be adequately deep cleaned. These significant shortfalls left people exposed to the risk of infection through poor infection prevention and control practices.

Most people and their relatives felt the cleanliness of the service was acceptable, but it could be improved. Concerns were shared with the inspection team regarding the laundry service, with named items going missing regularly, or being seen worn by other people. One person said, “The place is clean enough and I can shower as often as I like if someone can help me. My daughter takes my laundry home to do.” Another person said, “One cleaner does the whole floor and they do my room 2-3 times a week. They make my bed but it’s not tidied well as they’re in a rush, so I like to remake it and plump the pillows and tidy my blanket.” A relative told us, “My big concern is the laundry service as they lose so many of her things, even though they’re named. I’ve made a complaint.”

A member of the staff team expressed their frustration at lack of staff, impacting on their time to complete all required tasks to a high standard. We raised our concerns regarding poor infection, prevention and control practices with the management team to address.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Most people we spoke with told us their medicine taking was supervised, but several people with capacity told us that some staff would leave them with their medicines to take in their own time. Delays in the evening medication round were also commented upon. Some people we spoke with expressed concerns around the timings of their medicines. One person said, “I’m supposed to have my evening ones at 8pm but it gets later and later so I can’t get to bed and relax until I’ve had them.” Another person shared concerns around being consistently woken very early, to allow time for a gastric protectant medicine to be administered. The person explained how this impacted on their sleep hygiene and left them feeling tired later in the day. We raised these concerns with the management team to address.

Where people were prescribed ‘as required’ medicines, there were details on why this had been given, and how staff should identify people’s pain level if they were unable to communicate this verbally. Medicines care plans for people had been reviewed and updated since our last assessment. However, these required review with people and their relatives, to ensure an inclusive approach to supporting people with their medicines.

The management team understood who to report medicine concerns or errors to. However, if staff felt a person’s medicine was no longer effective, there was a lack of documentation to support this. Information showing which health professionals had been involved in these decisions was not always transferred into a person’s care plan or medicines risk assessment.

The provider used an electronic medicines administration system. The information held in this system had been reviewed and updated and showed correct stock levels of medicines. Prescribed topical creams were found to be stored securely, to reduce any risk from ingestion for mobile people. These topical preparations had a date of opening, with an associated body map detailing application sites and frequency.

The deputy manager explained how they were responsible for medicines management within the service and spoke of the improvements they were making to working in partnership with the covering GP practice, staff knowledge and processes. We were assured by their approach.