Wellington Park Nursing Home

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 good. 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 safe care and treatment. Specifically, this breach was linked to concerns about managing environmental risks and the lack of consistent, robust risk assessments for people. Another regulatory breach was in relation to staff training.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service managed and learned from safety events to improve the care for people. Staff were trained to identify and report safety concerns appropriately. Managers and senior staff worked collaboratively to embed good practice while promoting an open and honest culture within the service.

Staff understood the process of managing and reporting accidents and incidents, including falls. They maintained a clear log of these events, which was overseen by the nurses and the registered manager. The senior staff met regularly to discuss safety events and shared lessons with the rest of the team. Staff spoke consistently about their approach to managing safety events.

The service worked with people and health and social care 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.

When people were discharged from hospital into the service, the senior staff reviewed the referrals and communicated with the hospital wards to ensure all key information was captured. Where possible, senior staff, including the registered manager, visited people and invited them and their relatives to the service prior to their admission. This minimised people’s anxiety and ensured a smooth transition. The service followed a similar process for people referred from the community.

The service operated systems to protect people from abuse, neglect and discrimination. Staff understood safeguarding requirements and knew how and when to report concerns.

Senior staff reported safeguarding concerns to the local authority promptly and cooperated with safeguarding enquiry officers during their investigations to implement protection plans for people. Staff understood safeguarding procedures, including their responsibility to escalate concerns. If they had safeguarding concerns, a staff member told us they would, “Contact the manager, complete an incident form and contact the local authority or CQC”.

People told us they felt safe at the service. A person told us, “I have been here for years. I feel safe and well looked after by staff who I know.” A relative said, “I feel [person] is kept safe, because they know how to look after him. Staff talk to him, and he is just looked after so well.”

For people whose freedom was restricted, the service sought the appropriate legal authorisations when needed.

Staff collaborated with people, their representatives and health and social care professionals to identify and manage risks to people’s health, care and safety. However, guidance for staff on risk reduction measures was not always sufficiently detailed.

Risk assessments lacked clear information in some cases. For example, one person was assessed to be at high risk of developing pressure ulcers and their care plan only contained brief instructions for staff on how to reduce this risk. The care plan instructed staff to reposition the person but did not specify how often or in what manner this should be done. We also found gaps in repositioning charts. This could potentially increase the risk of this person developing pressure ulcers. Another person had diabetes and suffered from constipation; while these health issues were recognised and documented, clear instructions for staff to manage these risks effectively were lacking.

In other cases, we found individualised risk assessments where the service had implemented appropriate control measures to mitigate risks. For example, there were effective risk management plans for people who were at risk of falls. Staff followed guidance from healthcare professionals and made sure people’s safety was maintained by using the appropriate equipment when supporting them.

Some people and relatives expressed satisfaction in the way their safety was managed in the service. Feedback from relatives included, “Staff know [person] well. [Person] has to be hoisted by 2 staff and can get agitated but they handle it so well” and “They deal with the stoma bag well, and yes they certainly know what they’re doing with all her care.”

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment and facilities supported the delivery of safe care.

The service commissioned an external fire safety inspection in December 2024 that revealed most fire doors were not fit for purpose. While the service was in the process of repairing the fire doors and told us most of the doors had been repaired, a re-inspection of the fire doors to check they conformed to the required specifications was yet to be arranged. Since the service operated a ‘stay put’ policy in the event of a fire, the lack of urgent action to address the fire doors issue placed people at risk of harm. A fire safety recommendation from the service’s fire risk assessment of August 2024 had also not been met. Fire drills were not taking place regularly to make sure staff were prepared to deal with fire emergencies. People had Personal Emergency Evacuation Plans (PEEP) which were designed to help them stay safe in an emergency. However, these plans did not always contain clear instructions to ensure they were effective and robust. The London Fire Brigade had visited the service and was aware of the fire safety concerns.

During our site visits, we identified several concerns related to the physical environment. A number of bedrooms had not been adequately maintained. Equipment such as bed rails and furniture were not always in good condition. Several utility rooms, including electric cupboards and sluice rooms were not kept locked. Radiator covers were not fitted in certain areas to protect people from the risk of burns. These issues placed people at risk of harm. We also found various parts of the service showing signs of wear and tear.

The managers told us they had ordered new equipment and begun to redecorate the service. The service carried out regular premises checks, including in relation to gas safety, water systems and electrical installations.

The service deployed sufficient skilled and experienced staff, who received effective support and supervision. They worked together well to provide safe care that met people’s individual needs. However, there were shortfalls in the staff training programme.

Staff had access to a range of regular refresher training courses to help them remain up to date with best practice and the latest guidelines. However, although most staff were experienced in the care sector, they had not had training in some areas relevant to their work or the needs of the people using the service, such as diabetes, PEG feeding (feeding tube), swallowing difficulties, stoma care and Parkinson’s disease. This could make it difficult for them to support people with those needs safely and effectively. While care workers did not administer medicines to people, as the nurses did this, they were not trained in medicines management for awareness purposes. Staff were also not trained in learning disability and autism. In 2022, the government made it mandatory for CQC-registered health and social care providers to ensure their staff receive learning disability and autism training appropriate to their role.

The managers told us they had subscribed to a new online training platform in May 2025 and had access to more courses. They said staff were assigned new courses which they were working through gradually.

The service conducted the necessary checks to ensure staff were recruited safely. This included identity verification, seeking employment references and Disclosure and Barring Service checks (police check).

We observed staffing numbers were adequate, and people, relatives, visiting professionals and staff shared the same view. Comments from people and relatives included, “Staff usually come quick when I press the alarm button” and “There are plenty of staff. They frequently go in and have a chat with [person].”

The service assessed and managed the risk of infection. The premises, including people’s rooms and communal areas were clean and tidy.

Staff wore personal protective equipment appropriately. Kitchen staff adhered to safe food handling procedures to maintain good food hygiene.

However, slings used by staff to move and transfer people were shared among them and stored in communal storage cupboards. After we raised the issue, the managers acted promptly, removing slings from communal storage and assigning each person their own to avoid cross-contamination. We also found some shower drains were visibly unhygienic. The managers told us these would be replaced promptly.

The service made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff were trained and assessed as competent to manage and administer medicines.

Medicines were received, stored and returned safely and in line with the recommended standards. Staff completed medicines administration records (MAR) consistently. Medicines records highlighted any allergies people had and contained guidance for the administration of ‘when required’ medicines, such as painkillers. Records showed staff administered people’s medicines on time.

The service managed controlled drugs according to national guidelines. Staff recorded the opening and use-by dates on medicines with limited shelf lives to ensure safe administration. The process for administering medicines covertly was supported by the required documentation. The service did not store excess medicines.

However, people’s medicines records did not evidence the site of application of transdermal patches to ensure these were rotated appropriately. We raised this issue with the nurses who told us they would implement the necessary MAR promptly.