Wingates Residential 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 the way medicines were managed, processes to ensure the premises and equipment were safe, along with the provision of staff training and support.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not always work well with people to understand what being safe meant and how to achieve this. Although safeguarding concerns had been reported in line with guidance, the provider did not evidence safeguarding concerns had been fully investigated, analysed and reviewed to ensure people were safe.

The provider documented any safeguarding concerns or referrals to the local authority safeguarding team on monthly logs. However, information documented on the logs was very brief. There was limited to no details about the nature of the incident, what actions had been taken, the outcome and if any lessons had been learned and/or changes made to practice to keep people safe and reduce the likelihood of a re-occurrence. As a result, we could not be assured safeguarding issues had been dealt with effectively.

Deprivation of Liberty Safeguards (DoLS) are an important part of the Mental Capacity Act 2005. They involve providers seeking legal authorisation from the local authority where they need to deprive people who lack capacity of their liberty. For example, preventing them from leaving the care home without support, or having keypads on internal doors which prevents free movement. DoLS aim to ensure that such deprivation of liberty only happens when it is necessary, proportionate and in the person’s best interests. DoLS applications had been submitted as and when required, with a log used to monitor applications and their outcome. We noted the log had only been introduced following the change in management. We also noted some applications had only recently been submitted, despite the person residing at the home for many months. We noted this was due to the current management being unable to locate any previous applications or record one had been submitted.

People told us they felt safe living at the home. Relatives also felt their family members received safe care. Comments included, “I feel very safe and looked after” and “I feel that [relative] is safe here.”

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.

People’s care records contained a range of risk assessments, which were there to explain known risks and how these would be met or minimised by staff. However, we found some risk assessments and related documentation were contradictory or confusing. For example, one person was described as being unable to weight bear or walk, but a floor sensor had been introduced due to the risk of them wandering. Records also referred to the use of a stand aid, which requires a person to weight bear, as well as them requiring support of 2 staff to mobilise. This same person was reported to be unable to move position independently when in bed, however, there was limited information on how this risk was being managed and whether repositioning was being provided, to support good skin integrity.

Another person had experienced frequent falls, having 8 in the last 12 months. Records contained limited information on how this risk was being managed, what actions had been taken to reduce the risk of falls and whether they had been referred to the falls prevention service.

It was not clear from records viewed whether people had been actively involved in the risk assessment process, and if control measures had been collaboratively agreed.

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.

Moving and handling equipment, such as hoists and slings need to be checked and serviced every 6 months by an authorised company, to ensure they are safe to use and in good working order. We noted these checks had last been carried out in August 2024. We raised this issue with the provider, who agreed to look into this. We were later told, the contract with this company had expired at the end 2024. The provider was unaware of this, had not renewed the contract and as a result, the company had not completed planned servicing and safety checks in February 2025 and August 2025. Until we raised this issue, neither the provider or management were aware checks had not been carried out for over 12 months, despite audits of hoists and slings having been completed. The provider renewed the contract and arranged a visit for 18 September 2025 during the assessment process.

The provider had commissioned the completion of a fire risk assessment by an accredited external company in 2024. We reviewed this and noted a number of issues had been identified with actions generated to address these shortfalls. We saw no evidence any of the actions had been completed. For example, one action was to ensure evacuation sleds were purchased and put in place on stairways. None were present during out site visits. We also noted the provider’s fire evacuation procedure referenced the use of horizontal evacuation, whereas emergency evacuation plans completed for each person stated people to be supported to exit the building through the nearest and safest exit. Conflicting information may cause confusion in an emergency. The manager amended this information during the assessment.

Safety checks to ensure compliance with legislation and to keep people safe were not being completed fully or consistently. Checks of fire alarm call points were only completed monthly, rather than every week in line with guidance. We found no records to show cold water testing was being completed, as part of water safety checks to reduce the risk of Legionnaires disease. Hot water checks had been completed; however, we noted in August 2025, temperature of water in 8 bedrooms 1 bathroom and 1 toilet had exceeded recommended temperatures, with no action taken to remedy this. This increased the risk of people being scalded. We also found no evidence flushing of infrequently used outlets had been completed or that shower heads had been cleaned and descaled, again to minimise the risk of infection.

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.

Staff training compliance was documented on a spreadsheet. We were provided with an initial copy and later an updated copy of this spreadsheet, which showed completion rates for all training sessions was extremely low. Key topics necessary to ensure staff could provide safe care and meet the needs of people they supported, all had completion rates under 50%, most were below 30% and some had not been completed at all. For example, no staff had completed training in continence care, only 3 out of 34 had completed nutrition training, 18 out of 34 manual handling training, 13 out of 35 dementia training and 16 out of 35 health and safety training.

We also had concerns about the comprehensiveness of the induction process. New staff were provided with an induction checklist, which was detailed and covered all required areas of knowledge. However, each one we looked at had been signed off as completed within a day, which was not feasible. Following the assessment, the manager told us they reviewed, signed and dated the checklist upon completion, which is why only one date was documented. However, moving forwards, they would ensure each section was signed and dated upon completion. The provider’s induction policy stated all staff would also complete the care certificate, which is a set of standards developed for the health and care support workforce, to support their induction and development. It sets out the fundamental knowledge, skills, and behaviours required to provide quality, compassionate, and safe care. We found no evidence staff had completed this.

The provider’s supervision policy indicated staff would receive 1 to 1 sessions, at least 6 times per year, to review their work, ensure they are aware of their responsibilities and accountability, offer guidance and support and monitor progress in meeting appraisal objectives and targets. Appraisals would be held annually, with a 6 monthly appraisal review completed in between. We found neither appraisals nor the 6 monthly reviews had taken place. Supervision meetings had only commenced when the current manager had started working at the home, and whilst monthly meetings had taken place, only one of these meetings was in line with the provider’s policy, the rest had been meetings to discuss a particular topic, such as training completion or infection control practices.

People, relatives and staff told us enough staff were deployed to meet needs in a reasonable amount of time. The provider used a system for determining how many staff were needed to meet people’s needs. These are often referred to as a dependency tool. We were provided with a copy of this tool, which indicated 11 staff were required over a 24-hour period to meet people’s assessed needs. However, there was currently only 8 staff on shift per 24-hours, although following recruitment this was being increased to 9. We recommended the manager review the tool, to ensure it was accurate and if so, to review staffing levels.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

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

Medicines were not always managed safely. Upon commencing our review of medicines management, we found the medicines keys had been left on top of the medicine trolley. There was no risk assessment in place which covered the management or storage of keys. This issue had been identified in April 2025 through internal auditing, yet improvements had not been made or sustained. We also noted the key to the controlled drugs cupboard was stored on the same bunch as all the other keys. Best practice is to store this separately for safety.

Some medicines need to be stored at specific temperatures, and within a fridge. To ensure these medicines remain effective, fridge temperature checks need to be carried out. Although daily checks were being completed, they were not being done correctly, nor was the digital thermometer being reset each day, to ensure it recorded the accurate temperature.

From reviewing medicines records, we identified one person had missed 3 consecutive doses of several medicines due to being asleep when staff completed the morning medication round. There was no evidence to indicate staff had tried to administer these medicines later in the day, or if medical advice had been sought regarding the impact of missing these medicines.

Some medicine counts completed during assessment did not tally with the provider’s electronic medicine recording system (eMAR). This suggested people had either missed doses of medicines, been given them but they had not been recorded on the eMAR system or were unaccounted for.Following the assessment, the provider stated these discrepancies had been caused by the eMAR system automatically deducting doses marked as refused. This had since been corrected.

Where people are prescribed medicines to be taken as required, such as paracetamol, providers should have guidance in place for staff, which explains how and when to give this medicine, should the person be unable to request it. We found there was a lack of guidance in place, and what there was, was confusing and lacked detail. The manager admitted they had written these in between our site visits, as had identified none were in place at all.