Wray Park Care 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. This is the first assessment for this newly registered service. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment including the ways people’s medicines not being managed safely and cleanliness, safeguarding people from abuse and ensuring they were not subject to unlawful restrictions, staff deployment and training.
 

This service scored 28 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

There was no formal recording of any learning from any incidents of distressed behaviours. For example, the provider used an ‘ABC’ chart, which is an observational tool used to understand and identify triggers of distressed behaviour in people and create effective behavioural strategies. We saw from 1 person’s ‘ABC’ charts that they frequently got distressed however, there was no analysis of these incidents to determine what the potential triggers may be. The registered manager told us that only 1 person experienced emotional distress. However, we saw from another person’s care notes that over 14 days, they also experienced emotional distress on 4 occasions. Staff had not completed ABC records in relation to this. This meant there was a delay in putting in place strategies or preventative measures to reduce further risks. The service did not ensure debriefs for staff were taking place to understand and learn from incidents.

Whilst there was some review of other incidents for example in relation to falls and skin tears,the registered manager noted that no themes were found. There was no information on how they had determined this. This meant there was a serious risk people were subjected to avoidable harm as the provider had not worked to prevent incidents and accidents.

However, we did see that when an accidents and incidents did occur, actions were taken immediately to support the person including when people had falls.
 

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

We found where people were returning from hospital where they had been admitted for a period of time, leaders failed to attend the hospital to review their needs. The registered manager told us of 1 person that was due to return to the service after a number of weeks in hospital, “There's things like the discharge notes that come back. We'd read those and see if there's any changes or what they've put on there.” Providers should review the updated needs of a person when they have been in hospital before they return to ensure they can safely meet their new needs. A hospital stay often changes a person's health and care needs. The review helps staff arrange proper equipment, update medication plans, and train staff to prevent a return to the hospital.

We did see evidence of pre-admission assessments for other people that were due to move into the service for the first time. Records showed staff worked with healthcare partners including GPs, district nurses and specialist teams, ensuring joined‑up and timely support for these people. One relative told us, “[Senior staff] came and saw me, then spoke to mum and spoke to the physio in hospital.”

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

People were not protected from the risk of abuse or avoidable harm because there were no effective processes in place. Staff lacked an understanding of safeguarding and what constituted abuse. For example, 1 member of senior staff told us they would not consider verbal abuse between people a safeguarding concern. They told us, “Sometime people are verbal towards each other, swearing and shouting. Not a safeguarding. We calm them down with a cup of tea.” In addition, staff lacked an understanding of how to report safeguarding concerns to the local authority safeguarding team if required. This meant there could be a delay in appropriate actions being taken. The registered manager told us, “Definitely not all the staff would know [how to report a safeguarding], because I don't think they are confident.” However, knowing this, leaders had not taken sufficient action to address this.

We saw from incident and complaint records there were incidents of unexplained bruising and injuries to people who were unable to verbally communicate how this happened due to their cognitive decline. Leaders had not undertaken a detailed investigation to determine how this occurred. The registered manager told us, “I don't necessarily do a safeguarding investigation. I'll look at that and see if there are any sort of causes and if there are, what we can do to stop that happening again…. if there was like a bruise, we usually ask the doctor to come to look. I haven't got a specific record for that.” In addition, where safeguarding concerns had been raised by the local authority, leaders had failed to report this to the CQC as legally required. This lack of recognition of what constitutes alleged abuse meant that people were being placed at significant risk of serious harm and further abuse.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. We found leaders did not always ensure the legislation was complied with as some people were subjected to restrictions without the appropriate legal authority. For example, we were told by leaders that all people had sensor lights in their rooms. However, the registered manager and provider told us that no capacity assessments or best interest discussions had been recorded in relation to this. There were no DoLS authorisations in place for these restrictions where people lacked capacity. This was also the same for people that had bed rails.

However, feedback from people and relatives was that people felt safe at the service. Comments included, “I feel safe here” and “[Family member] is safe. Im happy, staff are great.” While people and relatives reported feeling reassured about safety, this did not mitigate the risks identified or the lack of effective systems to prevent abuse and protect all people from harm.

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.

People and relatives felt risks were managed well. However, we found risks associated with people’s care were not always managed in a safe way. This meant there was a significant risk people could be subject to avoidable harm. Leaders and staff told us how they managed people’s risks including the risk of dehydration, malnutrition, skin pressure damage risk management and constipation. However, we identified staff did not always understand or monitor people’s needs safely from both poorly completed care records and no action being taken where records had identified risks to people’s health and well-being.

The registered manager told us people’s hydration needs were not monitored. A senior member of staff told us staff recorded people’s fluid intake each day and that, “I go through and check the records.” However, we saw from care notes there were people that were frequently having less than 600 mls of fluids each day. One person’s average intake over a 2-week period was recorded as 430 mls a day. There was no record of any actions taken in relation to this. This meant people were at risk of dehydration and a deterioration of health.

There were no risk assessments in place for those who were at high risk of constipation. There was a lack guidance for staff on what signs to look out for if they had a concern with a person’s bowel movements. We noted in 1 person’s care notes that they had only opened their bowels 4 times over a 2-week period. Another person’s care notes showed they had opened their bowels 32 times in a 2-week period. There was nothing in either of these people’s care plans that there was a usual bowel pattern for either of them, or no record that this had been escalated. This placed people at further risk of becoming unwell.

Risk assessments were at times contradictory and did not always reflect people’s most current needs including whether people required support with their mobility or whether the person was at risk of falls. This meant staff may not provide the most appropriate safe care. There were also assessments missing in relation to known risks including (but not limited to) choking, skin integrity, oral hygiene and nutrition. Also, we saw from a smoking risk assessment for 1 person, which had not given consideration to all risks associated with smoking such as risk of burns. This meant people were at a significant risk of harm as there were serious shortfalls in the assessment of risk.

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 consistently protected from the risks associated with an unsafe environment because the provider had not always ensured the premises was well maintained and equipment safely stored.

There was a window with a warning sign stating ‘Keep window shut at all times’ however we observed this had been left open. We also observed rust staining from a corroded toilet brush holder. Rust is very porous and traps bacteria easily. There was a large damp, discoloured patch in one person’s bathroom. A rusted water mark on a bathroom wall can indicate an active plumbing leak, corroded metal pipes, or poor ventilation. This poses risk of mould growth, slip hazards, electrical fires, and compromised building structure.

We found people’s multiple prescribed topical creams had been left on the bathroom worktops. Not safely storing prescribed creams can pose several risks including improper application by a person and accidental ingestion. Also, bathrooms contain high heat and moisture, which can break down the ingredients and make the medicine ineffective in its use.

We observed a functioning hoist and a damaged hoist stored in corridors which were trip hazards. There was also an unlocked memory box containing loose drawing pins outside one person’s room. These shortfalls posed a significant risk to people’s safety and wellbeing.

However, the provider was able to demonstrate that other safety checks were in place. We saw an in-date Legionella risk assessment, up-to-date PAT (Portable Appliance Testing) testing records. PAT is the routine inspection and electrical testing of portable electrical equipment to ensure it is safe to use. There was also evidence that regular health and safety audits were carried out including fire safety and water temperature checks.

The provider did not 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 work together well to provide safe care that met people’s individual needs.

People were not supported by enough staff to ensure their needs were fully met and they received safe care. There were people cared for in bed on the lower and upper floors however, staff were not based on these floors. The people cared for in bed were unable to use call bells. Staff told us they relied on people’s sensor lights to alert them if the person needed them. However, given these people were unable to mobilise this was not an effective or safe way to ensure if people needed support, staff would be aware of this. This shortfall put people at significant risk of harm.

We also found that despite the service being a large building with 4 floors, there was only 1 housekeeper on duty for only 5 days a week. After the inspection, the registered manager told us they had now increased housekeeping staff to 2 during the week. They also told us that a member of staff had now been allocated onto the floors where people were cared for in bed.

The provider failed to ensure that staffing levels at night were safe. The registered manager told us 2 staff worked at night and there was also a ‘sleep in’ member of staff that could be called upon if required. They told us the ‘sleep in’ wasn’t rotered on shift and that the night staff would call upon a member of staff that lived at the service who was off duty. This arrangement relied upon these members of staff that lived there actually being at the service during the night shift. We also noted from the rotas that there was always a medicine trained member of staff who worked until 22.00 every day to administer night medicines to people. However, there were 5-night shifts in June 2026 where after 22.00 there was no medicine trained staff. This meant, if a person required ‘as and when’ medicine was required at 22.00 there were no staff on duty to administer this.

However, people and relatives fed back there was always sufficient staff. One relative told us, “In the week there is more than enough, whereas a bit less at the weekends. Always really well staffed though.”

The provider failed to ensure staff had received all the training they required in relation to people’s care needs. Of the 18 staff employed; 11 had not received basic first aid training, 10 had not received basic food hygiene training 8 had not received infection prevention and control (IPC) training, 5 had not received training in health and safety, and 4 staff had not received training in safeguarding, MCA, nutrition and hydration and dementia awareness. Where staff had received training and supervision, this had not always been effective in ensuring good care and practice as noted throughout this report.

There were people who were on a modified texture diet, yet no kitchen staff had received training on how to prepare this to the right consistency. We also observed that the pureed meal prepared for people had liquid surrounding the food. People on pureed diets often have swallowing problems. Food not being pureed correctly increases the risk of the food or liquid going into the lungs (called aspiration), which can cause pneumonia or increase the risk of choking.

The provider operated effective and safe recruitment practices when employing new staff. This included requesting and receiving references and checks with the disclosure and barring service (DBS). DBS checks provide information including details about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The provider had failed to ensure good infection prevention and control practices (IPC) which placed people at risk. We identified a strong malodour in 3 people’s rooms which remained all day.
The laundry room was not set up to ensure effective IPC. Dirty maintenance items had been left in there. The floor and drain were dirty. The sink area was degraded and stained and there were thick cobwebs underneath and around all the equipment. The skirting around the main desk area, where the medicines were stored was not clean with a build-up of dust and dirt. Where food was being stored, the wire mesh used in part of the door to this was thick with built up dust. The sluice room was also not kept clean and tidy. All this increased the risks of infection spreading and cross-contamination. This had placed people at significant risk of avoidable harm.

The hairdressing room [also used as a staff room] and parts of the dining room were not clean. We found the furniture and fans in some people’s room were covered in food debris and dust. People’s bed bumpers were stained with 1 also having food debris in the open seam. The windows in people’s room were covered in cobwebs. Although infection control audits were taking place, this was not effective in identifying the concerns we found.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Whilst there were some people that received their medicine as prescribed, the management of medicines was not safe.

We observed the temperatures of the corridors and the downstairs reception area where the medicine trolleys were kept recorded as 26 degrees Celsius. A member of staff told us the rooms where medicines were kept should not be warmer than 25 degrees Celsius. We asked how staff reduced the temperature of the trolley and they told us, “We open the doors of the trolley and stand in front of it until the temperature goes down.” However, when they did this, we noted the temperature increased to 27.6 degrees. The temperature checks lists that staff were completing were recording temperatures between 27 and 30 degrees. Staff were also only checking the temperatures once and, in the morning, when temperatures were cooler. No action had been taken when the temperatures exceeded the safe range, this meant there was a risk the effectiveness of the medicine was reduced. The registered manager told us they were taking action to address this.

Where people were prescribed ‘as and when’ medicines including Lorazepam for incidents of emotional distress. The registered manager told us, “We don’t like giving Lorazepam to people. It makes them not themselves.” However, we noted from 1 person’s medicine administration record [MAR] they were given Lorazepam on 4 occasions between the 27 April 2026 and 5 May 2026. Staff had not recorded on the medicine record why they had resorted to administering this medicine. Also, the guidance in relation to administering ‘as and when’ medicines lacked detailed and person-centred information for staff. This meant that leaders would not be assured that the medicine given was actually required. This meant people were at risk of inappropriate or overuse of medicines.

We found ‘as and when’ protocols for other medicines for people were identical and lacked detail including for eye drops and laxatives. This is required to ensure medicines are given consistently. In addition, 2 people’s MAR and medicines guidance had no photograph on them. A photo is needed to verify the right person is receiving the medicine.

The registered manager told us there were people that were at high risk of constipation and as such were prescribed ‘as and when’ laxative. We noted from their MAR that 1 person had been administered ‘as and when’ laxative for 28 days in June 2026 with no note as to why this was needed. We noted their bowel records for the last 2 weeks in June 2026 demonstrated the person was opening their bowels at least once (at sometimes twice) every day. At times the bowel movement was recorded as Type 6 on the Bristol Stool Chart, indicating mild diarrhoea. This may have been as a result of being administered too much laxative which in turn would also dehydrate a person.

We found some elements of the management of medicines that were safe. Where handwritten prescriptions had been entered onto the MAR, 2 staff had signed to confirm the accuracy. Where pain patches were applied to people, staff were recording where this had been applied. Body maps were used to guide staff where they needed to apply topical creams. Where people were receiving medicine covertly (disguised in food and drink), there was guidance in place for staff on what was safe to place the crushed medicines into.