Wessex Lodge 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 provider was in breach of legal regulation in relation to records (Good governance). Records in relation to risks associated with people’s care, medicines and safety incidents were not sufficiently comprehensive to ensure staff had all the information needed to keep people safe.

This service scored 59 (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 demonstrated elements of a safety culture, including systems for incident reporting and efforts to share learning with staff. However, the overall approach was not consistently proactive or sufficiently robust. Records lacked the necessary detail to support thorough investigation and transparent decision-making. For example, in incidents involving unexplained bruising, records did not clearly outline what information had been reviewed, how alternative causes were considered or ruled out, or why the incidents did not meet the threshold for safeguarding referrals. Inconsistencies across incident forms, body maps, monthly analysis, and care records, combined with limited safeguarding rationale, meant that lessons were not always reliably identified or embedded into practice.

People told us they felt safe and shared examples of changes implemented following incidents, such as the use of crash mats, sensor mats, and appropriate footwear to reduce the risk of falls.

Feedback from relatives was mixed regarding whether they felt adequately informed and updated following accidents and incidents. Comments included, “Anything I raised … they have addressed these”, “Communication is good, they phone me”, “[Person’s name] has a crash mat, fell out of bed … they phoned me immediately to tell me”, “I was told that it had happened 3 days earlier, they didn’t contact me straight away” and “Initially no problems but fell … and not informed quick enough ... I expect to get a phone call and don’t expect to be told 4 or 5 days later.”

The provider told us they had agreed communication preferences with relatives, including whether they wished to be informed immediately or at a scheduled time, and who should be contacted as the primary next of kin. They acknowledged that, in some cases, families with multiple contacts had not always been kept informed following incidents. In response, they reviewed and strengthened their processes to ensure people and their relatives were clear about contact arrangements and understood who would be notified by the home.

Staff told us they received the monthly incident analysis and felt that learning was regularly shared with them. They described a culture of openness and learning, where concerns could be raised without fear of blame. This reflected a positive approach to safety and continuous improvement. However, gaps and inconsistencies in records highlighted areas for improvement to ensure that lessons were effectively identified and embedded into practice. The provider told us they were taking action to improve the quality and consistency of their records.

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.

People and relatives confirmed that pre-admission meetings were held to identify individual support needs. Comments from people included, “They did come and see me. From the start they asked me lots of things about me and what I like” and “They knew all about me before I came to live here.” Relatives shared positive examples of coordinated efforts between the home and other care homes to facilitate smooth transitions for people. One relative told us, “[Person’s name] was in care home before and was arranged between the 2 homes, it went smoothly.”

When people were admitted to hospital, the provider prepared a hospital pack containing key information about the person and their medicines to support safe and consistent care. These practices were confirmed by both relatives and staff and reflected a joined-up approach to safety and continuity. One relative told us, “Care plan never seen it, saw a copy when he had a fall and was going to hospital … saw the pack out for the paramedics and took a copy of his meds.”

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

People told us they felt safe and were confident raising concerns with staff and leaders. Comments included, “Feel very safe” and “Staff keep us safe.” Relatives mostly felt people were safe and confirmed they knew who to speak to if they had concerns. Staff demonstrated a clear understanding of safeguarding principles and how to uphold people’s rights. Leaders showed they understood how to work with external agencies, including the safeguarding authority and police, when required. The registered manager told us they proactively contacted the safeguarding team to discuss incidents, which helped them determine whether the safeguarding threshold had been met in cases where this was unclear.

However, while staff and leaders demonstrated a clear understanding of safeguarding principles, we found that documentation and decision-making processes were not consistently robust. Leaders showed a commitment to protecting people’s rights, but inconsistencies in incident records and safeguarding rationale limited the effectiveness of safeguarding decisions and learning from incidents. We have reported on these shortfalls in more detail under the Learning Culture quality statement.

The provider aimed to work with people to understand and manage risks in a way that was safe, supportive, and person-centred. However, risk assessments and associated care plans were not always updated when people’s needs changed.

Risks were not always clearly assessed, leaving staff without sufficient guidance to provide safe, consistent care or support people in managing risks, for example, smoking-related risks.

We found that information across records was sometimes inconsistent or inaccurate, such as the dependency assessment for one person. Care planning records did not consistently reflect people’s current support needs; some lacked detail, contained outdated or contradictory information. Such as care plans relating to people’s emotional support and risk assessments for moisturising creams that can pose a fire risk if not used safely). This increased the risk of unsafe or inconsistent care and limited people’s ability to be active partners in managing risks.

However, staff demonstrated a strong understanding of individuals and described how they helped people manage risks, including those related to falls, smoking, and emotional distress. People told us they felt supported to make decisions and understood the risks involved when making lifestyle choices, for example, smoking.

The provider was responsive to our feedback and took prompt action to begin updating care records to improve consistency and oversight.

The provider detected and controlled potential risks in the care environment. Equipment, facilities, and technology were maintained to support the delivery of safe care. Effective systems were in place to monitor the safety and upkeep of the premises, including scheduled servicing and repairs. A dedicated maintenance team enabled prompt responses to issues and supported ongoing oversight.

Leaders were proactively considering environmental changes to minimise disruption and maintain safety. For example, they were exploring the installation of a stair lift to support continued accessibility, which would also be beneficial during any future lift replacement works.

People and relatives were positive about the premises and confirmed people could personalise their bedrooms. One relative told us, “We have personalised her room with her familiar stuff around her.” The home was spacious and fully accessible for wheelchair users, and equipment was monitored and maintained according to a regular schedule.

The provider had not consistently ensured safe and effective staffing across the service. Pre-employment checks were incomplete for some staff, including gaps in employment histories and missing verification for roles involving vulnerable adults. This did not provide assurance that individuals were suitably vetted and appropriately qualified for their roles.

Prior to the assessment, the provider had identified shortfalls in recruitment record-keeping through internal governance processes and had taken steps to centralise recruitment through the HR team. However, no new staff had been recruited into the service since this change, so its effectiveness could not yet be evaluated.

However, staff and relatives told us they felt staff were appropriately trained, and staff themselves confirmed they received regular supervision, training, and inductions. Records also supported this, reflecting staff development and oversight. This supported staff to carry out their roles safely and confidently and reflected a commitment to ongoing development and support across the team.

Feedback regarding staffing levels was mixed. While some people and relatives felt staffing was sufficient, others raised concerns, particularly about weekends, evening shifts, and support for people requiring assistance from more than one staff member. Staff described increased workloads during late afternoon and evening periods, especially when known risks such as sundowning were more prevalent. Ensuring staff presence in communal areas during these times was noted as a challenge.

We observed staffing levels appeared sufficient to meet people’s needs, with staff appearing responsive to people, and engaged with people in a calm and unhurried manner. Staff maintained a visible presence in communal areas.

In response, the provider shared staffing levels were monitored and reviewed regularly. Team meeting minutes showed active discussions around staffing roles and expectations, including steps to improve visibility and support, such as nurses being more present on the floor during key times. This reflected a proactive approach to addressing concerns and clarifying responsibilities to better meet people’s needs.

We identified some shortfalls in the provider’s approach to infection prevention and control. There were gaps in some cleaning schedules relating to people’s bedrooms and communal areas of the home, which meant it was not always clear whether all required tasks had been completed consistently. We received mixed feedback from relatives regarding unpleasant odours in bedrooms and corridors, which was supported by some of our own observations. One relative commented, “The flooring is coming away from the wall and germs can get in there.” Feedback from professionals also highlighted concerns about cleanliness, a professional told us, “I have noticed some of the patients’ rooms are very dirty.”

People told us the home was regularly cleaned and that staff used personal protective equipment (PPE) appropriately. Comments included, “All is really cleaned very well, can’t fault anything. My toilet is cleaned several times a day,” and “Cleanliness is over the top, deep cleaned on a routine basis.” Staff confirmed they had access to sufficient supplies of PPE and cleaning products.

Staff and leaders were transparent about the systems in place and acknowledged that odours could persist after carpet cleaning. The provider had taken action to address this, including replacing flooring in some areas and exploring external deep carpet cleaning services. During the inspection, we observed cleaning being carried out, including prompt responses to spills.

However, processes supported staff in following safe food hygiene practices. Regular checks confirmed kitchen cleaning tasks were completed and food safety measures, such as fridge temperature monitoring, were maintained.

The provider did not always ensure medicines and treatments were safe or consistently met people’s needs, capacities, and preferences. We identified shortfalls in medicines management that could impact safe and person-centred care. Records relating to variable dose medicines did not always contain sufficient detail to guide staff in determining the appropriate dose. For example, there was no clear guidance on how to assess or decide the correct amount to administer when multiple dose options were prescribed. Protocols for ‘when required’ (PRN) medicines were not always clear, leaving staff without adequate guidance for safe administration. For example, some PRN protocols referenced the Abbey Pain Scale, a tool used to assess pain in people who are unable to verbalise discomfort but did not explain how the score should inform dosage decisions when variable doses were prescribed.

Care planning records relating to medicines were not always updated in a timely manner, which could lead to outdated or incomplete information being used to guide care.

Inaccurate and incomplete medicine records increased the risk of medicine errors occurring which could result in ineffective symptom control, delays in treatment when needed, or staff administering too much or too little medicine.

A system limitation affected the electronic medicines records, causing some data to reset at the start of each medicines cycle. The provider was aware of this issue, and we observed no impact for people as a result. However, it meant staff had to re-enter certain information manually, which increased the risk of oversight and relied on staff vigilance to ensure continuity in people’s care.

Medicines requiring additional checks were appropriately managed. Records showed that people received their regular medicines as prescribed, and we observed staff supporting individuals appropriately with their medication. One person told us, “They always bring along the medicines at the right time. They give them to me and wait for me to take them. I have seen them checking things are right.”

People and relatives confirmed they were supported with their medicines, that reviews were carried out regularly, and that they had no concerns. One relative told us, “Medication no problems, they are reviewed every now and then, no worries on that.”

The provider was responsive to our feedback and took prompt action to address the issues identified