Archived: Ruth 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 inadequate. At this assessment the rating has remained inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to people’s safe care and treatment including the safety of the environment, cleanliness, the management of incidents and risks to people’s health. The service was also in breach of legal regulations in relation to people not being protected from abuse, safe staff levels, staff not receiving appropriate training and supervision, recruitment processes not being robust, and the lack of adherence to the principles of the MCA.

This service scored 25 (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 listen to concerns about safety and did not investigate safety events. Lessons were not learnt to continually identify and embed good practice. At the previous inspection we found accidents and incidents of distress were not recorded or completed in detail. At this inspection, we found this concern still remained.

The provider failed to ensure when incidents relating to distressed behaviours occurred, sufficient action was taken to investigate what the triggers may be. There had 18 recorded incidents of distressed behaviour between February 2025 and May 2025. Whilst there was evidence the provider had reviewed all of these, there was very little action taken to reduce further occurrence. The majority of the incidents recorded that as a result the person was asked why they behaved in this way and for staff to monitor the person’s behaviour. This was not sufficient mitigation from the provider to ensure the person and others were protected from the risk of further incidents occurring. There was also no evidence that detailed debriefs were taking place with staff to understand and learn from incidents.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

The provider made us aware that 1 person was told they were moving to another service. Records detailed that the person was very anxious about the potential move and this resulted in increased incidents of distress. Moving can be very a daunting change for a person with a learning disability. There was no evidence of any consistent support or help to minimise the disruption and distress.

Where people required medical procedures there was a lack of planning to reduce the distress this may cause. For example, the management team told us 1 person was due to attend a health appointment at hospital. We saw from the records the person had anxiety when attending particular medical appointments. However, there had been no planning undertaken to reduce the stress this may cause the person such as attempts at de-sensitisation or a ‘Social Story’ (an individually created story to help a person individual understand a situation and so reduce their distress. When we raised this with the leaders, they told us had used ‘Social Stories’ for the person before and would ensure this was done for the hospital appointment. However, staff we spoke to said they had never used ‘Social Stories’ with the person and said, “We bring something that he likes maybe a cartoon on the phone. Just play it and hold his hands.”

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. 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. At the previous inspection we found safeguarding incidents were not investigated appropriately or reported to the local authority. We found on this inspection this had not improved sufficiently.

People were being deprived of their liberty without appropriate authorisation to do so. One person had multiple restrictions placed on them including their wardrobe doors being locked by staff, having to hold staff’s hands all the time they were out and the front door being locked when they were in their home. There were no decision specific capacity assessments in relation to this or evidence of any best interest meetings to determine what least restriction options had been considered. There was no evidence these decisions had been re-visited to ensure they remained the least restrictive options in line with the MCA. This meant that these restrictions were being imposed on the person without the appropriate authority to do so.

The provider had not taken appropriate action to fully investigate safeguarding incidents to ensure people were protected from further risk. There had been 17 incidents of high levels of distress and whilst the provider had recorded these had all been reported to the safeguarding authority, there was no evidence of this or the outcome of these investigations.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Since the previous inspection there has not been sufficient improvement around the management of risks.

Risks associated with people’s care were not being managed well. One person’s care record indicated they had lost 2 kilograms (kg) of weight in June 2025, some of which they had now put back on. There were no records of any actions taken in relation to this including a referral to the GP. One member of staff told us they would not raise concerns about weight loss unless the person had lost more than 5 kg in a month. When asked why they believed the person may have lost the 2kg they said, “Probably he just lost weight. I know that he does tend to gain and lose weight here and there.” However, the care records do not reflect that the person was known to do this. The person’s Malnutrition Universal Screening Tool (a five-step screening method to identify adults at risk of, or suffering from, malnutrition) had not been completed to determine if they were at a safe weight. Leaders also told us they were not aware of how to accurately use the tool despite this being in the person’s care plan.

There was no formal monitoring of a person’s bowel movements. Their care notes showed multiple incidents of where either the person had not opened their bowels for 3 to 4 days or at times recording the person had a Type 6 or 7 bowel movement which could indicate the person was constipated. There was also no risk assessment in place for staff with guidance around signs to look out for should the person be constipated. Staff were also not knowledgeable around the monitoring of constipation. One told us they would raise concerns if the person had not opened their bowels for 2 days and when asked if they understood how to record types of bowel movements (based on the Bristol Stool chart) they said, “I don’t know about types.” They did however say that they would raise concerns if the person had loose bowels or struggled to pass a bowel movement. People with a learning disability are at a significantly higher risk of constipation compared to the general population, and it can have serious or even life-threatening consequences if left unaddressed.

Staff’s understanding of the risks associated with people’s care varied. For example, 1 person’s meals had to cut up as they had a tendency to eat quickly. This reduced the risk of them choking. However, one member of staff incorrectly told us, “(Person) has dysphagia. So cut up the meat for him into small pieces so easily chewable.”

Other risk assessments lacked detailed guidance and were not person centred. This included in relation to skin integrity, choking and health conditions. This was despite a manager telling us they had recently transitioned from paper care plans to electronic and that, “You will get more information from the (electronic care plan).” We found this was not the case.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. Whilst there had been some improvements since the last visit we continued to identify concerns.

Since the last assessment, the maintenance of the garden had improved. However, the paving slabs were not secured and rocked when walked on. The manager told us that people liked to hang their washing out on the line in the garden, however they would have needed to walk over the stones to get to the washing line. The radiators now had covers over them however they were not fixed securely. Some of the doors on the upper kitchen cabinets were not secured safely.

There were areas of the environment checks that were undertaken and were effective. This included fire safety checks, water temperature and PAT testing on electrical equipment.

At the previous inspection, the provider did not make sure there were enough qualified, skilled and experienced staff. They did not work together well to provide safe care that met people’s individual needs. We found on this inspection this had not improved.

Whilst there were sufficient numbers of staff on duty, the provider failed to ensure staff were not working excessive shifts on a row. Leaders told us staff would not be rostered to work more than 3 awake night shifts in a row. The manager told us, “Three shifts is maximum because we have different staff who are working so that staff don’t overwork themselves.” The provider told us, “We are taking into account the recommendations from the last inspection so that staff are not overworked.” However, we saw from the rotas for September 2025 that 1 member of staff worked 5 awake nights and 4 awake nights in a row. This risked the member of staff being fatigued and placed people at risk. In addition, staff fed back they were allowed to work 4-5 nights in a row and had not been told that 3 nights were the maximum.

Whilst staff received training and supervision this was not effective in ensuring the safe delivery of care as noted through this report. Whilst staff had worked with people for many years and spoke of them fondly, they lacked a good understanding of autism and learning disability. Comments from staff on their understanding of autism and learning disabilities included, “That means certain things he cannot perform” and “(It means they are) unable to do everything and sometimes challenging behaviour.”

Although there were records of supervisions were taking place, these were not effective as we identified shortfalls in practice in all areas of care being provided. In addition, where supervisions were recorded, these were not an accurate reflection of discussions with the member of staff. For example, 1 supervision recorded a conversation with a member of staff referencing one of the providers’ other services. The provider confirmed this member of staff had never worked at that other service. This meant the member of staff had not received a supervision relating to Ruth Lodge.

The provider did not operate effective and safe recruitment practices. Although work had been completed by the provider to update staff files following our last inspection, we still found that checks did not comply with Regulation 19, specifically schedule 3. Of the 4 staff files we reviewed, only 1 had the complete work history. One member of staff did not have a fully completed interview form, including information of who caried out the interview. One staff filehad a reference from an employer that was not listed on their work history. This meant the provider could not be assured of the staff’s suitability to work at the service.

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.

Since the last assessment the cleanliness had improved however there were still some concerns. One person’s bedroom had a slight smell of urine that remained throughout the day which the manager also acknowledged. However, no action had been taken to address this prior to our visit. We found the ceiling light fittings had not been cleaned appropriately and contained multiple live and dead insects.

In all other areas the home was clean, tidy and well stocked with cleaning materials and personal, protective equipment. One relative told us, “100% it’s clean and hygienic.”

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.

There were no people at the service that were prescribed medicines. However, we raised concerns with the leaders that there were also no ‘as and when’ pain relief prescribed and no homely remedy pain relief. This meant if a person became unwell and required paracetamol, they would need to be prescribed this by the GP. The manger told us it could take around 2 hours before they were able to get the prescription. This meant there could be a delay in providing pain relief. There was also no clear guidance in place alert staff when a person who was unable to verbalise pain required pain relief.