Dorrington House (Wells)

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 inspection we rated this key question Requires Improvement. At this inspection the rating has changed to good. This meant people were safe and protected from avoidable harm.

The service was previously in breach of the legal regulation in relation to safe care and treatment, staffing and fit and proper persons employed. Improvements were found at this assessment, and the service was no longer in breach of this regulation.

This service scored 69 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider conducted investigations when incidents occurred and took appropriate action to prevent recurrences. Staff attended regular meetings, which helped ensure any learning from events was shared and actioned.

The provider had policies and procedures for responding to incidents, accidents and complaints and staff we spoke with were knowledgeable about these. Staff told us they were aware of all the policies and felt confident about how to respond and report correctly.

People’s representatives also told us that lessons were learned when things went wrong and improvements were made. For example, a person’s representative told us how they raised a concern with the care team about their relative’s feet and legs. They explained that their relative was subsequently seen by the GP and said, “[Name] got antibiotics and it cleared up quickly. I know [management] has something in place now to ensure residents’ feet and legs are checked."

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Suitably trained staff completed and regularly reviewed assessments of people’s health and well-being, risks and wishes, to make sure they accurately reflected their needs.

Care plans were developed and shared with health and social care professionals when required, such as GPs, dietitians, physiotherapists and community mental health teams, to ensure people’s well-being was supported and maintained. Staff worked effectively with health and social care professionals to make sure people received appropriate support that met their needs.

A person’s representative told us how their relative had recently needed to go into hospital and said, “They supported [Name] quite well with that admission and returning back [to the care home].”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Information was on display throughout the service that reminded staff how to speak up and report any concerns and to also inform people and visitors to the service. People and their representatives told us they felt safe and well cared for. Comments included, “Yes, absolutely. I feel [Name] is safe. A person living in the home told us, “I feel a lot safer now than I did before. I wasn’t managing very well on my own [at home].” And, “[Care staff] are very good and I would soon say if they weren’t.”

The provider had safeguarding policies and procedures in place. Staff were knowledgeable about recognising potential abuse and harm and told us they had completed training for safeguarding adults, which was renewed every year. Staff said they were confident that any concerns raised would be managed appropriately and confirmed they always reported any concerns and followed the whistleblowing policy if needed.

We saw that the manager maintained a close working relationship with the local authority’s safeguarding team. They shared any concerns and information quickly and appropriately with them, as well as with CQC. We saw that investigations were carried out and action was taken to solve issues wherever possible and where necessary.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff completed risk assessments with people and care plans were developed to mitigate identified risks. For example, nutrition and hydration, falls risks and skin integrity. People’s risk assessments and care plans were regularly reviewed to ensure they continued to reflect people’s needs and remained effective in helping people to keep safe.

People’s representatives told us they were happy with the way their loved ones were supported to manage identified risks. A person’s representative told us, “They [care team] have done things over time, such as risk assessments, changed medication and reviewed things etc.” Another person’s representative explained, “[Name] had 3 or 4 falls. So what they [care team] have done is put a mat in [Name]’s room, which sets off an alarm. Now they also have a barcode system where staff check every half hour.”

The provider did not consistently detect and control potential risks in the care environment.During our site visit on 19 May 2026, we identified issues regarding environmental safety, such as people’s wardrobes not being secured to the walls and damaged or missing seals on people’s bedroom doors and some internal fire doors. Some people’s bedroom furniture was broken or damaged and needed replacing.

We highlighted and discussed these issues with the regional manager and registered manager, who took immediate steps with the provider to rectify the issues.By the time of our return site visit on 11 June 2026, we found that significant improvements had been made. These included wardrobes being secured to the walls and new bedroom furniture had been bought and installed. We saw that doors had been adjusted where needed and new seals had been fitted. The regional manager also assured us that they were working closely with the fire department to ensure all areas remained compliant in respect of fire safety.Additional work was also in progress, such as the redecoration of some rooms.

Although the provider was compliant with this quality statement by the end of our inspection, our scoring and rating reflects the need for the improvements to become embedded and be maintained.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Most people, their representatives and staff, said they believed there were enough staff employed and deployed throughout the home. However, a few people’s representatives commented that the service could do with more staff at the weekends, although they also said that staff still responded quickly and remained attentive to people’s needs.

The provider had safe recruitment practices to help ensure suitable staff were employed. Necessary pre-employment checks were completed before staff began working in the home.Staff completed regular training, to make sure they had the knowledge and skills to carry out their duties. Staff confirmed they received regular support and supervision and all spoke highly about the quality of the training and support they received.

A member of staff told us, “We have regular staff meetings and supervisions and appraisal meetings. I had induction training when I started my employment and shadowed other staff at that time. I regularly do the training [online] and also the in-house training. I think we all work well as a team.”

People and their representatives also told us they felt the staff were well trained and ‘knew what they were doing’. One person’s representative told us, “Yes, I do. I have no fault with the staff.”

The provider did not consistently assess or manage the risk of infection. They did not always detect, identify and control the risk of it spreading.During our site visit on 19 May 2026, we identified some issues regarding cleanliness and infection control. These included unclean furniture in people’s bedrooms, as well as heavily stained toilets and sinks in people’s en-suites.We highlighted and discussed these issues with the regional manager and registered manager, who took immediate steps with the provider to rectify the issues.

By the time of our return site visit on 11 June 2026, we found that significant improvements had been made. The home was considerably cleaner throughout, particularly in people’s bedrooms and bathrooms. The management team acknowledged the shortfalls and assured us that they had immediately ‘stepped up’ their walk-arounds and auditing processes.

Lots of people commented on the improvements during our 2nd site visit. A member of staff told us, “We have done a lot of changes and have more cleaners. We are very happy with the changes that have been made since you were here last.”

Although the provider was compliant with this quality statement by the end of our inspection, our scoring and rating reflects the need for the improvements to become embedded and be maintained.

People and their representatives told us they felt the cleanliness within the home was generally good. One person commented, “It’s mostly fine, but it can slip slightly when staff are short.”

Staff confirmed that they had completed training for infection control and also had sufficient supplies of Personal Protective Equipment (PPE), such as gloves and aprons. A member of staff told us, “I have been fully trained in infection control procedures and we always have ample supplies of PPE.”

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.Medicines were managed and administered safely. Records were up to date, people’s allergies were recorded and appropriate risk assessments were in place, including those covering the use of emollient creams that may contain oils or paraffin.The GP carried out regular medicines reviews with people and PRN medicines used to manage agitation and anxiety were not excessively used to control people’s behaviour.

People and their representatives told us that staff managed medicines well and people received their medicines on time.For example, a person’s representative told us, “They [staff] are pretty good at medications. They went through them and explained to us and [Name] why [Name] was having them.” Another person’s representative said “[Name] gets their medication on time – they [staff] are very regular.”

Staff who managed and administered people’s medicines confirmed that they had completed training and had their competency checked regularly. They also confirmed their understanding of the procedures to follow in the event of any concerns or errors.A member of staff told us, “I had training online, the policy and practical advice. If something happens, we always report to the person in charge. We are always learning. I had my observations done and they [senior staff] checked me. The process went on for some days. I was asked if I was happy to do it alone; it was at my speed.”

We identified that the medicines cupboard for controlled medicines, may need moving for health and safety purposes. This was because the cupboard was so low, staff needed to go on their knees to open it.