Welshwood Manor

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 changed to 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.

The service was in breach of legal regulation in relation to people’s safe care and treatment.

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.

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.
At the last inspection, we were concerned that the culture within the home was not always focused on safety or learning from incidents that had occurred. At this inspection, we found the manager was trying to make improvements; however, the systems and processes for monitoring and analysing incidents were not sufficiently robust. This was important because without effective systems to review and learn from incidents, there was a continued risk that patterns or causes of harm were not identified, and improvements were not consistently made to enhance people’s safety.

The manager and staff team worked with people and healthcare partners to maintain systems of care. However, the systems in place did not consistently identify when safety concerns had arisen or when further action was required. This meant there was not always effective oversight of safety, and areas of need were not always recognised independently. Consequently, appropriate referrals to partner agencies were not always made when required.

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. Where safeguarding concerns were raised, these were appropriately investigated by the provider and shared with relevant external partners, however, not all staff demonstrated a clear understanding of their responsibilities in safeguarding people as some people were supported with care according to staff preference.

We found not all staff had received safeguarding training, or where they had some was out of date. This meant people were at an increased risk of abuse as staff may not identify and appropriately report signs of abuse.

Systems were in place to support the appropriate application of Deprivation of Liberty Safeguards (DoLS), and the management team demonstrated an understanding of when referrals were required and the process to make these.

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. On the first day of our inspection significant shortfalls were identified in the management and support of individuals with swallowing difficulties and at risk of choking. The provider had not taken all reasonable steps to mitigate risks and improve the safety of individuals who had swallowing, eating and drinking difficulties.

Nutrition and hydration care plans were not consistently updated in line with Speech and Language Therapist guidance or the International Dysphagia Diet Standardisation Initiative (IDDSI). IDDSI provides a standard framework for food textures and drink thicknesses for people with swallowing difficulties (dysphagia). The framework includes Levels 0–7, with food textures classified from Levels 3–7. In one case, an individual was placed on a Level 6 IDDSI diet without proper consultation and assessment. The wrong level textured diet could have placed them at risk of choking. Care plans also lacked clear strategies to ensure supervision during mealtimes, particularly for those eating in their rooms.

Staff, including catering staff, had not received adequate training in dysphagia or IDDSI, limiting their understanding of safe food textures and preparation. There were no effective systems to ensure kitchen staff were informed of, or adhered to, individuals’ dietary requirements to ensure the correct preparation of food for people to meet their dietary needs and reduce risk.

On the second day of the inspection we found improvements, in response to the urgent concerns we found, the manager had taken action to make urgent referrals for healthcare support and updated risk assessments. The manager had also sourced training and support urgently for staff, so they had the skills to recognise potential risk and support people safely

People were not cared for in a safe environment. 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. There were no effective arrangements in place to check the safety and upkeep of the premises, and address issues that presented a potential risk to the health and safety of people using the service. The previous inspection in October 2025 identified that the external grounds were not safe or secure, and these concerns remained. Following the inspection, the provider replaced both padlocks with combination locks to improve accessibility for staff while maintaining security. This ensured staff were aware of and able to use the access codes, supporting safer and more timely access in the event of an emergency.

At the rear of the garden, there was a low metal fence. Although wire mesh had been added between the bars, this would not prevent a determined individual from climbing over. There were also maintenance sheds in poor condition, with rotting wood and broken glass. Both contained hazardous chemicals, and 1 shed did not have a sufficiently robust lock to prevent unauthorised access.

A fire risk assessment conducted by an external contractor on 17 October 2025 identified multiple deficiencies across the premises. These included issues with directional signage, fire extinguisher signage, lift signage, certification for maintenance of equipment, fire door inspections, and staff fire safety training. In total, 19 actions were required, of which 5 were assessed as medium severity and 14 as high severity. While some medium-risk actions had been addressed, the higher-risk actions had not been satisfactorily completed. Following the first day of our inspection the provider stated that arrangements had been made to complete the required remedial works.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,

supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Feedback from staff was staffing levels were generally sufficient. On both days of our inspection visit we observed staff attending promptly to people’s needs and supporting people with kindness and patience.

We identified some gaps in training for a small number of staff. The registered manager advised us this was being addressed to ensure staff had the appropriate skills.

There were procedures to ensure the required checks were completed prior to staff commencing their employment. This included enhanced Disclosure and Barring Service (DBS) checks for adults. DBS checks provide information including details about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions. Improvements were still needed, however, to the on-boarding process for new staff with regards to checking staff work history thoroughly.

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.

The previous inspection identified hygiene and infection control concerns including dirty toilets and ineffective laundry processes. Whilst improvements to the interior décor had been made and the premises were clean and tidy; further action was needed to protect people from the risk of acquiring infection. Issues included a lack of enclosed toilet roll dispensers to keep the paper protected from airborne dust and splashes when the toilet was flushed increasing the risk of spreading infection.

Cleaning regimes and laundrypractices required improvement to ensure compliance with current legislation and best practice guidance. The laundry environment was observed to be cluttered and busy, making it difficult to maintain cleanliness and further increasing the risk of contamination. The industrial washing machine was not operational, and there was reliance on a domestic washing machine. While management indicated plans to purchase another domestic machine, this would not meet required standards.

During both days of the inspection, it was observed that the yellow clinical waste bin was overfilled, with clinical waste bags overflowing and additional bags deposited on the ground surrounding the bin. This indicated the provider was not adhering to their own Disposal of Domestic, Hygiene and Special Waste Policy (February 2026). The policy stated that hygiene waste must be stored in a large, secure, and easily cleaned bin, typically supplied by a waste removal company. It further specifies that bins must not be overfilled and that lids should remain closed at all times when not in use. These measures are intended to prevent pests, such as squirrels, from accessing and dispersing waste, thereby reducing the risk of environmental contamination and potential health hazards.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Systems were in place to ensure the safe storage, administration, and recording of medicines. The service had a medication trolley on each floor, with each trolley containing a folder holding people’s individual information. This included a list of prescribed medicines, the reasons for prescribing, maximum daily doses, and medication administration records (MAR).

The service used a monitored dosage system, with medicines pre-packed by the pharmacy. Administration was recorded on MAR charts, and there were no gaps in recording, indicating people received their medicines as prescribed. Where boxed medicines were in use, staff appropriately carried out stock checks and recorded quantities brought forward, ensuring accurate stock balances.

People’s consent to receive medicines and their preferences for administration had been sought. Individual profiles included information about people’s capacity to consent; however, this information was not always consistent or accurate. For example, one person’s profile stated on the front page that they had capacity, while the reverse stated they had dementia and lacked capacity. This inconsistency could lead to confusion and inappropriate decision-making. The manager took action to address this.