Last updated: 9 February 2026
"Enough trained staff and a positive open culture, but incomplete risk assessments and weak auditing fail to ensure safety and oversight."
Risk assessments were not always completed for known risks or detailed to guide staff; fire safety risks like smoking in rooms not robustly assessed; incidents not reviewed for patterns; breaches of Regulation 12.
People, relatives and staff spoke positively about the open culture at the service. Staff told us they felt listened to and were able to suggest improvements, 'I feel respected working here. [Registered manager] is open to our suggestions. We work well together as a team.'
There were enough suitably trained staff to meet people's needs and keep them safe. Robust recruitment processes were in place to ensure staff employed were safe to work with the people living at Davigdor Lodge.
Per 2019 comprehensive inspection: Staff had received the support and training they needed to care for people's needs including mental health awareness, substance misuse, with regular supervision and opportunities for qualifications.
Registered manager in post and described as approachable by staff and relatives, but auditing systems were not robust or effective to ensure management had oversight on identifying risk.
Per 2019 comprehensive inspection: Activities were mainly offered on an individual basis such as craft work, cooking, chatting with staff, and occasional organised outings like meals at the pub.
Risk assessments are often incomplete or missing details for dangers like fire safety and falls, so staff lack clear guidance on keeping people safe.
Risk assessments were not always completed for known risks to people or were not detailed to guide staff to support people safely. Risks to fire safety had not been assessed and mitigated.
Managers' quality checks and audits on risks and incidents are not done regularly or thoroughly, missing chances to spot and fix problems early.
Auditing systems were not robust or effective to ensure management had oversight on identifying risk and acting on lessons learnt. The concerns found during this inspection had not been identified through internal quality assurance processes.
No dedicated activities coordinator or varied programme, so days are mostly routine care with just basic individual crafts and occasional outings.
Per 2019 comprehensive inspection: Activities were mainly offered on an individual basis. We observed people engaging in some craft work, cooking, and chatting with staff on an individual basis.
AI Generated
Last inspected: May 2023
Management Quality
Well-led: Requires improvement
Direct feedback from current and former employees

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