Weavers 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

This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. We found people were not fully protected from poor care and abuse. Staff did not always support people with their medicines in a safe and effective way. Risks to people had not been fully considered or planned for. Staff did not always have sufficient skills, experience or knowledge to meet 1 person's needs. The provider was therefore in breach of regulations in relation to safe care and treatment and safeguarding service users from abuse and improper treatment. This was a breach of Regulation 12 (Safe care and treatment) and Regulation 13 (Safeguarding service users from abuse and improper treatment) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were using a service where the current learning culture did not always promote lessons learnt from incidents. This was due to inconsistent recording by staff. This meant not all incidents were able to be reviewed properly and any analysis carried out to learn lessons would not be based on completely accurate information.

The registered manager acknowledged our concerns about inconsistent reporting. They told us they would take action to ensure staff recorded each incident in line with the provider’s policy. This would ensure fully accurate records would be available. Staff told us incidents and accidents were discussed in team meetings and handovers. Staff were provided with a debrief when more serious incidents occurred. One staff member said, “I always offer a debrief to staff if there's been an incident. Sometimes this can be a quick discussion immediately after the incident, but we can also spend time to discuss it in more detail if we need to.”

The service had systems in place for staff to report and record accidents, incidents, and instances when people were displaying anxious behaviour. However, there was no consistent staff approach to recording. This meant neither the registered manager and/or the provider’s behaviour support specialist could analyse them effectively to establish patterns, reduce recurrence and support people in a proactive way. The registered manager and provider were proactive following our feedback during the assessment. They started making improvements to their systems and processes to ensure a consistent approach to recording.

People who wished to move to the home had their needs assessed. This process was designed to make sure it was the right place for each person and their needs could be met in a safe and effective way. The assessment for 1 person had failed to determine staff at the home did not have the skills of experience to meet their extremely complex care needs. In addition, the provider’s assessment process did not consider whether people living together at the service would be compatible with each other or if their lifestyle would have an adverse effect on others living at the home. One person’s transition had not been well managed. There was limited information about the person, combined with a lack of integrated transition planning with the person and their previous care provider.

The registered manager initially told us the assessment process was comprehensive. Through discussions and review of both assessments carried out, we found there were significant issues with this process and needed to be improved. It was apparent 1 person’s needs could not be met and they were placing themselves and others at considerable risk. Staff told us, “One of the residents requires more support that we cannot deliver at Weavers lodge. Weavers lodge is not the right home for that individual” and “[Due to 1 person’s behaviour] As a support worker at Weavers Lodge, I am finding it hard to effectively support and safeguard the residents and keep myself safe at the same time.”

We did not receive any feedback from other health or social care professionals regarding the provider’s assessment or transition processes. The registered manager told us they had not been provided with either fully complete or entirely accurate information about 1 person during their particular assessment of need. The new assessment process should ensure this does not happen again.

One assessment of need had been carried out by the registered manager. The other person’s assessment was carried out by the registered manager, deputy manager and the provider’s positive behaviour support manager. Following the significant issues with 1 person’s care, and through discussions with us during our visits, the provider has reviewed and significantly improved their assessment process. They have shared the new assessment format with us.

People were not always safe living at the home. One person was placing themselves at significant risk. They were also placing the other person who lived at the home and staff members at risk. One person said, “[Name’s] shouting again. He's unhappy. I feel sorry for him.” They also told us they often felt scared when the other person was displaying anxious behaviour. It was therefore identified that the home was unable to meet 1 person's needs. During our assessment process, 'notice was served' on this person's service [meaning an alternative service needed to be found for them]. There was a delay in finding a suitable alternative service, despite other health professionals becoming involved. The provider continued to provide care beyond the expiry of the notice period until a suitable alternative service was found.

Staff had been trained to recognise and report safeguarding concerns. Staff spoken with raised serious concerns with us about people’s safety and the safety of staff. One staff member told us, “Weavers Lodge is not very safe for residents and staff and needs to be improved due to safeguarding [incidents].” Another staff member said, “The staff find it really difficult. I would say that staff are afraid of [name of person 1]. He is really unpredictable. [Name of person 2] is afraid of [name of person 1] and will hide behind the sofa or staff will have to safeguard and take him upstairs to his room [to keep them safe].” The registered manager confirmed on 3 December 2024 1 person would be moving from the home urgently as it was not possible to provide safe care to them. They were working with other health care professionals to source a suitable alternative service.

People and staff did not look comfortable or relaxed during our visits. There was often a tense atmosphere primarily due to 1 person’s levels of anxiety or unhappiness. We observed serious incidents during 2 of our visits. These adversely affected the person and also the other person who lived in the home. It was evident staff were unable to keep people and the environment safe at all times.

The provider had safeguarding and whistle blowing policies in place. Staff worked with appropriate agencies to ensure safeguarding concerns were reported and investigated. The provider worked with other professionals to ensure that any restrictions were kept under review and were appropriate. Where people were unable to consent to restrictions, the correct process had not been followed. A decision specific process should be followed and this had not always been done. The provider assured us the necessary improvements would be made. The provider made applications for people to be legally deprived of their liberty where they needed this level of protection to keep them safe. We were told there were no conditions applied to people’s deprivation of liberty authorisations. This was not correct. One person had 1 condition applied which had not been complied with. This was discussed with both the registered manager and the nominated individual who assured us this will now be shared with all staff and complied with.

People and staff were at risk, particularly when 1 person had high levels of anxiety or unhappiness. It was not possible for staff to manage risks at these times. These incidents were becoming more intense and more frequent. This meant the level of risk was increasing. This was also having an adverse effect on the other person who lived at the home. Emergency measures were being taken at times to try to ensure they were not at risk. We saw on 1 visit they were taken to their bedroom and on another visit they had been asked to use another part of the home rather than the lounge they usually used. One family member told us, “Clearly this move [to the home] is not working out and is not the right place for him. No one really understands what has happened to [name] or what his needs are. [In their opinion, his care and support needs] are well outside the skills of staff in residential homes.”

Staff understood some of the risks to and from people who lived at the home. Staff were able to tell us about the risks faced by people and the staff team. One staff member said, “Weavers lodge is not the right home for 1 individual. This makes it challenging for staff as you can get hurt at any time if you are not careful. Staff are getting [hurt] which makes it hard to support the individual.” Another staff member said, “Things have gotten worse. I would say [name’s] behaviours have gotten worse. They are more extreme. We still use the method where we try to keep a safe space between us and if he is having an episode, but make sure that we can still observe him. There is no other intervention.” Whilst it was evident and commendable the provider wanted to continue providing care to 1 person, it had become “unsustainable”, due to the risks to people and to the staff team.

We saw how people, staff members and the environment were at risk during these times. Although staff did their best to provide safe care, it was simply impossible for them to do this at times. One person often became incredibly distressed, physically and emotionally. At these times they could cause significant property damage and could harm themselves and others if they attempted to intervene. Staff withdrew direct support, keeping a safe distance, but made sure they could observe the person at all times.

Risks to people were included in their care plans. We found risk assessments needed to be improved, including when carrying out assessments on people new to the home. Not all risks identified during assessments had been added to people’s care plans to ensure consistency of support and mitigation of known risks. This placed people, staff and potentially members of the public at risk of harm. There had been no impact assessments completed for the 2 people currently living at the home detailing the risk they might pose to each other. Therefore, risks and people's compatibility had not been fully considered.

People did not currently live in a homely environment or one which was entirely safe. One person had caused a substantial amount of damage to the environment. This included breaking windows and items of furniture and damaging/removing internal doors, some of which were fire doors.

Staff and the registered manager told us emergency repairs were carried out as much as possible. Additional measures had been implemented in respect of fire safety as an interim. The full repairs needed could not be completed until 1 person moved to a more suitable service. It was anticipated after this person moved, it would take approximately 1 to 2 weeks to complete.

We viewed communal areas, people’s own rooms and rooms which were not yet being used. It was evident the home had originally been refurbished to a high standard by the provider prior to people moving in. Some areas were not being used and retained this level of refurbishment. Other areas currently in use had suffered high levels of damage. These included the kitchen, dining area, lounge and 1 person’s own room.

There were a range of checks designed to ensure the safety of the environment. These included checks on hot water temperatures and fire safety. Fire safety was currently compromised as some fire doors had been removed and others badly damaged during incidents in the home. Glass panels within internal doors had been broken and were ‘boarded up’. Whilst some interim measures had been put in place, such as staff physically checking the building at set times, fire safety was not in line with the fire risk assessment. This would not be possible until all of the repairs to the home had been carried out.

People were supported by an appropriate number of trained staff. One person told us they liked the staff who supported them. Two relatives told us their particular family member needed specialist support which the home’s staff could not provide. One relative said, “Clearly [living here] is not working out and is not the right place for him. He clearly needs real professional help that are well outside the skills of staff in residential homes.”

Staff were generally happy with the training they received, but felt they needed more training in supporting people with complex behaviours. One staff member said, “I think that staff need more training due to various incidents and dealing with difficult behaviours. I am very wary of [name]. I would say that staff are afraid of him, they are wary of him when they need to work with him. I think that [name] knows this and this adds to his anxiety.” Similar views were shared by most staff members we spoke with. Staff felt generally well supported. One member of staff told us, “They provide training to the staff as well as supporting the staff wellbeing.”

We observed staff supporting people on a 2:1 basis in the home and supporting people to access the community. Where people wanted privacy or if they did not wish to interact, we saw staff respected this but remained near-by in case people wanted or needed support. It was evident staff were fully committed to the service and clearly trying their best to provide good quality, safe care to people. However, we saw 1 person was extremely complex and staff were clearly struggling to support them. We saw, and some staff told us, they were very anxious around this person.

Staff training records showed a variety of training had been provided. Most training was ‘on line’ with 50 courses available. We noted 1 staff member had completed all 50 courses in the same day. Other staff had completed 19 and 22 courses respectively in 1 day. This was not in line with the provider’s expectations as it would be difficult for staff to learn and apply training at this pace. The registered manager responded immediately when we raised this issue with them and will ensure on line training and completion will be closely monitored and staff knowledge reviewed. There were enough staff to support people. When agency staff were needed to provide staff cover, the same agency staff were used whenever possible to ensure consistency in staffing. Staff were recruited safely. Recruitment records showed all pre-employment checks had been made to ensure only staff who were suitable to work with people were employed.

People lived in a clean environment. No one raised any concerns about infection control practices.

Staff told us they received infection prevention control training. Staff training records confirmed this.

Although the environment of the home had suffered extensive damage in some areas, we observed the home to be clean and odour free. We observed staff cleaning areas of the home on each of our visits.

There were systems in place to monitor infection prevention and control measures in the service. For example, the registered manager was carrying out a weekly walkaround which included monitoring of the cleanliness of the home.

One person was supported with their medicines by staff in the home. They were happy to show us their medicines and where these were stored. The other person living at the home was supported by a health professional with their medicine each month. There had been a delay in administration when this person first moved to the home but this had now been resolved and regular monthly administration organised.

Staff said they received training in the safe administration of medicines and had their competency assessed before supporting people. One staff member told us, “I am not yet medicines trained so cannot [support people with this].”

Medicines were not always managed safely. At the time of the assessment only 1 person was supported with their medicines by staff. Their medicines were not always stored safely as temperatures of their medicine storage area was not monitored and recorded. The provider did not ensure that people's homely remedies' protocols were reviewed and agreed with the GP. This placed people at risk of receiving medicines which were not suitable for their needs. When medicines were administered while the person was out of the home, the electronic medication administration record would not record the administration until they returned to the service. This meant medicines often being recorded as being administered ‘late.’ There was no effective system in place to confirm if medicines had been taken at the right time or if they were late. This increased the risk of the next dose of medicines being administered without the correct time gap. The provider’s medicine audit did not pick up the concerns we identified at this assessment.