Wainford House Residential 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. At our last assessment we rated this key question Good. At this assessment the rating changed to 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, premises and equipment, safeguarding people from abuse and improper treatment and staffing.

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.

Leaders and staff did not record incidents and accidents consistently. This contributed to lack of investigation to understand how people had been placed at risk of harm, and any learning to mitigate future risks to people.

We were made aware of incidents which should have been reported either to the local authority safeguarding team or to the CQC but which had not been reported by the provider or their management team. This meant prompt action was not taken to minimise the risk of the concerns happening again. The provider did not ensure there was a consistent process in place for recording and reviewing accidents and incidents and sharing any learning with staff. Therefore, the provider did not ensure all risks were mitigated and care plans updated to reflect any changes in people’s individual needs.

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

Care plans did not demonstrate that people had always been referred to external professionals when necessary. For example, we observed a person struggling to stand from a chair. There was no record of a referral to an occupational therapist for an assessment as to whether they needed equipment to support them stand.

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.
Staff had received safeguarding training but failed to demonstrate they understood how to put their training into practice. We found examples where staff had failed to recognise safeguarding concerns and take the appropriate action to keep people safe or report to relevant external agencies.

During our inspection we identified incidents which should have been referred to the local authority and to CQC as a safeguarding concern, but these had not been reported. These delays and omissions raised serious concerns about the provider’s compliance with safeguarding requirements and their duty to notify relevant authorities promptly. When partner agencies are not informed, people at significant risk of harm are deprived of the appropriate action needed to ensure their safety.

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 that some staff demonstrated an understanding of their responsibilities about the Mental Capacity Act (MCA) however this was not consistent for all staff. Staff told us they had received training in MCA and explained they would always seek consent before supporting a person. However, we observed incidents where this did not happen. We saw a staff member not getting a person’s permission before putting a tabard on them when they were getting ready for their lunchtime meal and another member of staff moving a person in their wheelchair without explaining they were about to move them.

Records of people’s capacity were contradictory, and phrases were not always clear as to their meaning. For example, one person’s care plan recorded that they were ‘fully minded’ but in another part of the care plan a box was ticked saying they had an impairment of, or a disturbance in the functioning of the mind or brain. Whilst MCA and DoLs systems were in place we were not assured that people’s capacity had been appropriately assessed to protect their rights and the DoLS applied when necessary.

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.

The service’s record of accidents and incidents requested by inspectors during the inspection showed that a person had sustained 12 falls during August 2025. It recorded the care plan had been reviewed but did not record if any action had been taken, such as a referral to a health professional or falls team to mitigate risks. During our second visit on 17 September 2025, we requested the area manager review accidents and incidents. The information provided showed the person had sustained 9 further falls from 3 September to 18 September 2025. It also recorded that the person should trial a pressure mat to alert staff when they were mobilizing. There was a significant delay from identifying the risk of falls to the person being supported to reduce and manage that risk, which placed them at increased risk of harm. No action had been taken to mitigate the falls risk for the person until inspectors requested a review of incidents.

Another person’s care plan recorded they were at high risk of falls and required a Zimmer frame to walk independently. The risk assessment for slips, trips and falls dated 8 September 2025 in their care plan had not been fully completed and recorded ‘not at risk of falls’. However, the falls risk assessment also dated 8 September 2025 identified them as a very high risk of falls. The care plan stated that the person had been referred to the falls team who felt equipment and support was in place but there was no date of contact with the falls team or when this information was shared with the home. There was no evidence the falls team had been contacted in August or September? 2025. The only actions recorded in the care plan to mitigate their falls risk was for staff to encourage them to use their frame. No action had been taken until prompted by inspectors.

The dependency assessment in another person’s care plan stated they had no difficulty eating and drinking and did not require adapted cutlery. The nutritional assessment in their care plan recorded they had no difficulty eating, chewing or swallowing. No choking risk was identified. The section of the care plan entitled ‘assistance required’ is blank. The section for utensil use recorded a normal cup to be used. During both of our inspection visits we observed the same person spilling food down their front, storing food in their mouth and struggling to get porridge onto a spoon and into their mouth. We also observed the person using a cup with a straw and a plate guard. The eating and drinking risks for this person had not been appropriately assessed, increasing the risks of aspiration, choking, and compromised nutritional intake.

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.

We received mixed feedback from relatives regarding the environment. Some people told us it was clean and well maintained but others raised concerns regarding the cleanliness and safety of the building.

We looked at the cleanliness and maintenance of the premises. We found that furniture and equipment across the service was in a poor condition, damaged and could not be cleaned effectively. For example, perch chairs had split fabric which presented a risk to people with a poor skin condition and also meant they could not be cleaned effectively. Blinds and curtains in the communal lounge were stained and in poor condition. Waterproof seals around toilets and baths were not always smooth which meant they could not be effectively cleaned. There were trip hazards such as uneven floors and raised door treads which increased the risk of falls.

Suffolk Fire and Rescue Service had identified serious concerns with fire safety in the building and had put a prohibition notice on 5 bedrooms due to serious safety concerns and taken further enforcement action.

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.

The provider did not ensure that everybody working in the building had the appropriate checks in place and that a risk assessment had been carried out for the proposed works and what impact this would have on people living in the service. During our first inspection visit there were several contractors working in the building. We asked the management team what checks had been carried out to ensure contractors were safe to work in the care environment. They were unable to assure us that appropriate checks had been carried out. We spoke with one of the contractors on the day of our inspection who confirmed that their staff all had a Disclosure and Barring Check, but the management team had not asked if this was in place or verified this.

The provider had not reviewed staffing levels to take into account the disruption which the building works had caused. For example, they had not increased staffing levels to take into account the lack of lighting in toilets due to maintenance work which meant people needed to use toilets which were further away from the communal areas that meant it took staff longer to support people to use the toilet.

We received mixed feedback from relatives and staff as to whether there were sufficient staff. A relative said, “The care home appears always well staffed.” However, another relative said, “The shortage of staff is unsafe as well and it’s like they [people] are just sitting around waiting to die.” Staff also provided mixed feedback. A member of staff said, “There are enough staff members

during night shifts and days.” However, other staff raised concerns regarding the number of staff on shift particularly at night.

During our inspection visits we observed call bells ringing for extended periods of time with no response from staff. There was no effective audit of call bells to check if there were sufficient staff to answer them promptly. Managers could not be assured that call bells were being responded to appropriately. The call bell audit in place checked the bell was working but not the response time.

Observations by inspectors demonstrated that staff did not have the skills or did not proactively interact with people. For example, during the lunch period we observed staff sitting next to people with no interactions other than to complete a task such as remove an empty plate. The activities coordinator told us that they had had no formal training to provide activities for people living with dementia.

The provider’s dependency tool used to assess staffing needs was not fit for purpose and did not accurately assess people’s individual needs. This document was contradictory and not fit for purpose; it did not explain fully the level of needs of people and how the total care hours for each person had been determined. For example, one person was cared for in bed and was fully dependent on staff for all their needs. The dependency tool reflected this person as having high dependency and no one with very high dependency. It was not clear why this person had not been recorded as very high dependency.

The accommodation at Wainford House is spread across 3 levels with bedrooms on each level, there is a rear extension with further bedrooms. The rear extension is accessed via the communal areas on the ground floor. The staffing tool did not demonstrate how the layout of the building was considered when determining staffing levels. Neither did it demonstrate consideration of the increased risk due to non-compliance with fire safety legislation and the building works taking place to remedy the non-compliance with fire safety legislation.

The dependency/staffing tool did not demonstrate how staffing levels for each shift were assessed. The staffing numbers on nights were reduced by 1 between 20 and 29 October 2025, with no clear explanation recorded for this change. The falls record for October 2025 recorded 7 falls by service users. Of these falls 4 occurred between 8pm and 8am when there were only 2 staff on duty. This had not been investigated by managers to see if the cause of these falls were in relation to staffing levels.

The manager spoken with on 29 October 2025 told us that they had been told to reduce the number of staff due to “business reasons”. They told us the dependency assessment was carried out by head office without their involvement. Carrying out this type of assessment remotely did not demonstrate that the changing needs of all service users had been considered when arriving at staffing levels, particularly in view of the quality and accuracy of the care plans which would need to be relied on.

The activities plan displayed in the service showed that staff were required to provide 1:1 activities for service users after 5pm. There was no activities co-ordinator in the service at that time of day. This was not reflected in the staffing tool.

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.

There were areas of the service which were not clean or well maintained. The cleaning records did not describe how an area should be cleaned. For example, they stated ‘deodorise rooms’ with no explanation as to how this should be done. For example, the seals around some toilets and baths were not smooth. This meant they could not be effectively cleaned which increased the risk of infection. There was a very strong smell of urine in a bedroom and adjacent corridor. We observed a toilet brush which did not have a cover. This meant there was a risk of infection being spread from the brush.

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.

On our first inspection visit of 17 September 2025 the service medicines trolley was not secured to a fixed point or in a locked room. This is contrary to Royal Pharmaceutical Society guidance for medicine storage in healthcare settings which states ‘Medicine trolleys are lockable and secured at an anchor point (i.e. a point at which trolleys can be secured to the floor or wall) when not in use. Alternatively, medicines trolleys may be stored securely in a locked room when not in use if access to the room is restricted to authorised persons.’

Homely medicines were not kept secure in a locked cupboard. Part of the lock was missing, meaning the cupboard could not be secured. The cupboard contained liquid and topical medicines as well as homely remedies. The cupboard was in a communal area which all service users had access. This meant service users could gain access to medicines which were not appropriate for them.

The service did not have a procedure to ensure medicines which were no longer needed were disposed of appropriately. Staff told us that any medicines which were not required, such as when a person had died or their medicines were discontinued by the GP, were handed to the manager. The manager in place on our inspection visit on 29 October 2025 confirmed there was no process for the recording of medicines to be disposed of. NICE guidance states, ‘Care homes should keep records of all medicines (including controlled drugs) that have been disposed of or are waiting to be disposed of. Medicines waiting for disposal should be kept in a locked cupboard until they are collected or taken to the pharmacy.’ The service was not complying with this guidance.

Controlled drugs were not managed in accordance with best practice. A quantity of 72 Zomorph 10mg capsules (controlled drug) were in the register but missing from the cabinet. Staff told us these had been taken by the police after the person’s unexpected death, but the service was unable demonstrate this had been the case. A person was prescribed diazepam, but the tablets were stopped by the GP with a last dose on 23 October 2025. The MAR chart showed there should be 14, 5mg Diazepam tablets left in stock. We checked the previous months MAR chart which also clearly showed 14 Diazepam 5mg tablets in stock plus 18 carried forward. None of these Diazepam 5mg tablets could be located by the service.

Protocols describing when people should receive medicines which were prescribed to be administered as required (PRN) lacked sufficient person-centred detail about their administration. This put people at risk of being given medicines when they did not require them or not being given medicines when they were needed. For example, a person was prescribed Cosmocol, the PRN protocol did not include the period of use and when a referral to GP was needed. The medicines administration record shows the medication was given most mornings. Another person was prescribed Clonazepam 0.5mg half a tablet 3 times daily as needed for anxiety. The medicines administration record (MAR) showed it had been administered each day at 8am. Records show the medicine being given for anxiety but does not record how the anxiety was demonstrated, what actions were taken to address the anxiety before giving the medicine or if the medicine was effective in relieving the anxiety. This demonstrated unsafe medicines management practices and placed people at risk of avoidable harm.