The Wells 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 requires improvement. At this assessment, the rating has remained 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.

This service scored 62 (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 registered manager had a system to review accidents and incidents and to identify any patterns and trends. Relatives confirmed they had no safety concerns and were informed of any falls or accidents involving their family member. One relative told us, “They ring me if there is a concern and brief me whenever I come in.”

Where concerns were identified regarding wound management at the home. The registered manager had sourced additional wound training for the nurses to undertake.

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.

The registered manager carried out a preadmission assessment of needs for new referrals, before deciding whether the home would be able to meet and provide the care and support required. Care plans were developed from the preadmission assessment and involved people and their relatives.

The provider used an electronic care system which care staff could access to understand the care requirements of people.They also had access to a folder in each person’s room with quick prompts about the person’s personal care needs.

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. The provider shared concerns quickly and appropriately.

Staff had received training in how to safeguard people and told us they would not hesitate to report any concerns. People told us they felt safe and knew how to raise concerns about any abuse or neglect. Everyone we spoke with felt the service was a safe place to live. One person told us, "I’m glad that I am here, I’ve been in another home, I think, here is wonderful, I am happy, the staff are very nice, I can’t fault them.”

A member of staff told us, they hadn’t witnessed any staff being unkind but said if they did, “I will speak to someone senior to me, if it was not dealt with, I’d speak with the manager, then the general manager and if all fails, whistleblowing and the Police.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found improvements had been made since our last inspection. MCA assessments were carried out and best interest decisions made. We discussed that it was not always clear who had been involved in the best interest decisions and the decisions being made. Action was taken to address this.

The registered manager made DoLS applications and worked with the local authority DoLS team about authorisations. We discussed that staff were not always aware if a person had a DoLS in place and the restrictions applied for. The registered manager told us they would add this information onto the electronic care system so staff were informed.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The procedure for assessing, monitoring and mitigating risks within the care environment, were not effective. We identified concerns in relation to aspects of fire safety. Action was taken during the assessment to address these concerns.

All people living at the service had personal evacuation plans in place which were regularly reviewed. Improvements were made during the assessment regarding advise to staff in the event of a fire.

On the first day of our visit, we identified that some people’s walking frames had worn ferrules. This meant the walking aid might not be fully effective to ensure grip and stability. Action was taken to replace worn ferrules and a monitoring sheet was put into place to regularly check them.

People’s risk and care plan information was held on the provider’s electronic care system. Care plans provided staff with information and guidance to support effective management of associated risks. This included identified risks, in relation to falls, skin care and malnutrition. However, we discussed with the registered manager that the risk assessment to assess people’s risk of skin breaking down was not always completed accurately and was often assessed as very high. This meant the plan of care put in place did not accurately reflect the support the person required. The registered manager reviewed everybody’s risk assessment to ensure they had been accurately completed and the right support was in place to minimise the risks to people of their skin breaking down.

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.

People were not cared for in a safe environment which was well-maintained, and which supported staff to deliver safe and effective care. On the first day of our site visit, we identified numerous concerns. For example, staff had a maintenance log they could record maintenance concerns. Some of these concerns had not been acted upon and the registered manager was not aware of the concerns. For example, fire doors which had not closed when the fire alarm went off. This meant in the event of a fire; people could be put at risk of not being protected by a fire door.

Electrical sockets in the kitchen could not be used and an extension lead was in use, which was a significant safety hazard. This had been reported to the provider; however, action had not been taken. A linen door which the provider’s fire risk assessment stated should be locked, had no means to be locked and was left open. In general, the home was in a poor state of repair and the décor tired. We discussed these concerns with the provider’s general manager and registered manager. On the second day of our site visit they had acted upon most of the concerns we found and where there would be a delay in actions being taken, a risk assessment had been put into place to minimise the risks.

Regular servicing was carried out to ensure equipment, such as fire detecting equipment was safe.

The Food standards agency undertook an inspection in January 2025 and awarded a 5, their highest star rating. Where they had made some minor recommendations, these had been acted upon promptly. This indicated that the home had particularly good food hygiene standards.

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.

During our inspection we saw there were enough staff to meet people’s needs and keep them safe. We observed staff supporting people at mealtimes and found there to be appropriate support with regards to the level of engagement with people whilst supporting them. Staff demonstrated they understood their roles. We observed that people appeared relaxed and at ease when being supported by staff.

People and relatives told us they felt there were enough staff to meet their needs and there was a consistent staff team, which they found reassuring. Comments included, “They’re very good, they answer the call bell quickly”, “There are enough staff, it is very friendly, they take good care of her, it is first class” and “She is well looked after here, there is always staff around, I think that there is a team upstairs and one downstairs, I think she has regular carers, I see the same faces when I come in, the staff are lovely.”

Where there were gaps in the staff rota, agency staff were used. Agency staff new to the home had an induction and had information shared with them about people’s needs.

Robust checks were carried out to ensure the suitability of staff during the recruitment process. This included references and an enhanced Disclosure and Barring Service (DBS) check. Staff had an induction when they started working at the service which included training and working alongside more experienced staff to learn people’s individual needs.

There was a system in place to monitor that the nurses working at the home remained registered with the Nursing Midwifery Council, (regulator that ensures those practicing as a nurse in England meet the required standards for conduct and practice).

Staff had the training and support they needed for their role. A person told us, “I think that the staff are trained to meet my needs.”

The provider had implemented training on learning disability and autism into their training schedule.

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.

On the first day of our site visits, not all areas of the home were clean and cleaning schedules did not reflect that all areas had been cleaned.

We found that fans which might be used if someone was hot, were dirty and increased the risk of cross infection. We raised this with the general manager and registered manager and they acted upon our concerns. On the second day of our site visit, the home was clean and new cleaning recording schedules had been introduced and a process to regularly clean the fans had been introduced. A more robust process had been implemented with weekly spot checks to be undertaken.

Staff had received training in infection control practices. They had access to PPE around the home. A person confirmed staff used PPE, they told us, “When they bed wash me, they use gloves and aprons.”

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.

People received their medicines safely and in accordance with prescribed instructions. We observed there were effective systems for ordering, storing, and disposing of medicines, including those requiring refrigeration or secure storage. The pharmacist who provided the medicines at the home had undertaken a visit in March 2025 and had identified no issues. They had recorded, ‘Excellent medicines management’ on their report.