Saxby Lodge Residential Care Home

The inspection was undertaken to follow up on previous warning notices issued to the provider. The provider was previously in breach of the legal regulation in relation to safe care and treatment, staffing and good governance. Improvements were found at this assessment, and the provider was no longer in breach of these regulations.

People were protected from abuse and avoidable harm. The provider had made significant improvements to incident reporting, risk management, staffing and medicines management. Staff understood safeguarding responsibilities, people’s medicines were managed safely, and there were enough suitably trained and recruited staff to meet people’s needs. The home was clean, and effective infection prevention and control practices were followed. However, some environmental risks had not been identified or fully mitigated through the provider’s own checks, including unsecured service areas and maintenance concerns. Leaders acted promptly when these were raised, but further work was required to ensure environmental monitoring was consistently effective.

People’s care, treatment and support achieved good outcomes. Their health, care, communication and wellbeing needs were thoroughly assessed, and care was delivered in line with evidence-based guidance. Staff worked effectively with health and social care professionals and made timely referrals when people required additional support. People received a varied diet and spoke positively about the quality and choice of food. Care plans and risk assessments were regularly reviewed to reflect changing needs, and staff worked within the principles of the Mental Capacity Act 2005. Where people lacked capacity, decision-specific assessments and best-interest processes were completed appropriately.

People were treated with kindness, compassion, dignity and respect. Staff knew people well, understood their individual preferences and communicated with them in ways they could understand. People, relatives and professionals consistently described staff as caring, attentive and approachable, and our observations showed positive and natural interactions. Staff responded promptly when people needed support and promoted a comfortable, inclusive environment. However, people did not always have sufficient choice or opportunity to participate in meaningful daily activities. Although community outings and special events had increased, the range and quality of routine activities did not consistently meet everyone’s interests and abilities.

People received personalised care that reflected their physical, emotional and mental health needs. Care plans contained clear guidance for staff, and people and their relatives were involved in decisions about care and treatment. People were supported to raise concerns, and feedback was gathered through surveys, meetings and informal discussions. People’s equality needs and future wishes were considered within care planning, including preferences for emergency and end-of-life care.

The service was more consistently managed, and leaders had driven significant improvements in the quality and safety of care. People, relatives and staff described the registered manager as visible, approachable and responsive. Staff felt able to speak up and reported improved training, communication and support. Leaders promoted an open, inclusive culture and worked effectively with external partners. Governance and oversight systems had been strengthened, resulting in improvements to incident reporting, risk management and staff practice. However, these systems were not yet fully embedded or consistently effective, as some environmental and maintenance risks had not been identified through internal monitoring. Leaders responded promptly to these concerns, but sustained oversight was required to ensure improvements were maintained and all risks were identified and addressed.