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 inspection we rated this key question Inadequate. At this inspection the rating has changed to Requires Improvement. This meant some aspects of the service were not always safe. There was an increased risk of harm and limited assurance about safety.

The findings identified repeated breaches of Regulation 12 (safe care and treatment) and Regulation 15 (premises and equipment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider did not consistently assess and reduce risks to people’s safety, manage medicines safely or control infection risks. Premises and equipment were not consistently clean, suitable for their intended purpose or properly maintained.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Since our last inspection, the provider had improved staffing arrangements, daily allocations and oversight of care. Governance reports recorded zero incidents of safeguarding’s or concerns but did not demonstrate that information had been checked against other records to identify unreported events. This limited opportunities to identify patterns, understand underlying causes and prevent problems from recurring. This reduced the effectiveness of the provider’s governance systems because leaders could not be assured that the information they used to monitor the service provided a complete and accurate picture of people’s care and any associated risks.

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 generally received ongoing healthcare support when they needed it. Records showed that GPs and district nurses supported people, and staff responded when people's health needs changed. This meant people were supported to access appropriate healthcare when their needs changed, helping to maintain their health and wellbeing and reduce the risk of deterioration or unmet health needs.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The provider shared concerns quickly and appropriately. People and relatives said they felt safe. Staff had received safeguarding training and explained how they would report concerns to senior staff, management or the local authority safeguarding team. We discussed with the manager the need for greater scrutiny and analysis of information to provide assurance that the absence of reported safeguarding concerns reflected people’s actual experiences and did not mean concerns had gone unidentified and unreported.

The Deprivation of Liberty Safeguards (DoLS) protect people's rights when they lack capacity to consent to care arrangements that deprive them of their liberty in a care home or hospital. Providers must seek the appropriate authorisation for these arrangements and meet any conditions attached to it. Where the provider had applied for DoLS authorisations and received approval, these authorisations were in place.

The provider failed to adequately assess and mitigate risks to people’s safety when moving around the home. We identified potential hazards, including low stair rails and trip hazards, that the provider’s own systems had not identified or addressed. We observed a person using mobility aids to climb the stairs from the ground floor to the first floor. They appeared unsteady on their feet and at risk of falling. The provider used generic risk assessments that did not consider this person’s individual mobility needs or the risks they faced when using the stairs.

Posters on display gave instructions directed staff to routinely turn lights off, due to consideration of carbon omissions. However, these left people moving around in dimly lit conditions. The provider had not adequately considered this practice alongside people’s individual mobility and falls risks or alternatives such as motion sensor lighting. These failures left reasonably foreseeable risks unresolved and exposed people to an increased risk of avoidable falls and injury.

Care plans identified individual risks relating to falls, pressure damage, nutrition, mobility and medicines. However, records contained conflicting information about people’s mobility, continence, falls and pressure damage risks. The provider had not ensured these records gave staff consistently accurate and reliable guidance on supporting people safely. These inconsistencies increased the risk that staff could provide inappropriate or inconsistent support or fail to recognise and respond to changes in people’s needs. Together, these findings demonstrated that the provider had failed to assess and manage risks effectively and protect people from avoidable harm.

The provider had not ensured the premises were consistently safe, suitable and well maintained. Progress in addressing repairs and environmental improvements had been slow, and several issues remained outstanding at the time of our inspection.

Areas of the home were poorly decorated and in a state of disrepair. Some windows were significantly misted, restricting people’s ability to see outside clearly from their rooms. The condition of the environment did not consistently provide people with comfortable, well-maintained surroundings that supported their wellbeing and quality of life.

People also raised concerns about the temperature of the home. One person told us, “It is always cold in here,” while another said, “I put the heater on, but the cleaner turned it off.” A further person described problems with their radiator and said they had needed to use blankets and coats to keep warm. Feedback also reflected wider concerns about the suitability of the premises, with one person commenting, “The building itself is not the ‘best in class’, which does have some drawbacks.”

People and relatives gave mixed feedback about staffing levels. Some said their needs were met and staff responded promptly. Comments included, “I press the buzzer, they [staff] come quickly any time, mornings, afternoons, evening weekends and nights.” And “There is always plenty of staff on the floor… Staff are attentive and quick to respond to [people]”. Others raised concerns about staff availability, saying, “Nobody is here to take me out in the wheelchair, there is not enough staff.”, “Staff are stretched at times” and “Each shift could do with one more staff to cover unplanned things.”

Staff told us there were enough staff and sufficient time to carry out their duties and support people safely. During our visits, we observed enough staff to meet people’s needs. Staff were visible and available when people required support.

Recruitment records were not always complete. Some lacked references or explanations for gaps in employment histories, making it harder to confirm that recruitment checks were sufficiently robust. Agency staff were not individually named on the rota, leaving no clear record of who worked each shift. Accurate shift records help the provider identify who cared for people, account for all staff during an evacuation and establish who is available to help people leave safely. They also enable the provider to identify and speak to staff involved in incidents or concerns. Without these records, evacuation checks and investigations may be delayed or more difficult. The provider was transferring staff records to an electronic system and taking action to address these gaps. However, incomplete records limited oversight of staff working in the home and increased the risk that concerns about staff suitability, or accountability would not be identified promptly.

Staff told us they received relevant training and supervision. However, several staff had no monthly supervision recorded in August and September 2026. The provider could therefore not show that all staff received formal support and oversight at the expected frequency. This increased the risk that development or support needs would not be identified and addressed promptly.

Infection prevention and control practices were not always effective. The environment was not consistently clean or well maintained. During both of our inspection visits, we observed dirty light pull cords, damaged and stained furniture and inadequate waste arrangements. Some damaged surfaces could not be effectively cleaned, which increased the risk that effective infection prevention and control practices could not be maintained.

The provider completed infection prevention and control audits in August and September 2026, both of which recorded 100% compliance. However, these audits had not identified the concerns we found during the inspection. This meant the provider’s monitoring systems were not always effective in identifying shortfalls and taking action to address them, increasing the risk that poor infection control practices could continue and expose people to avoidable risk of infection.

Medicines were not always managed safely and consistently. Some ‘as required’ (PRN) protocols were missing, inaccurate or lacked sufficient guidance. Allergy information and medicines risk assessments were not always complete or accurate, and risks associated with flammable topical medicines had not always been assessed. Some medicines prescribed for one person’s end-of-life care had expired. These were replaced during the inspection, addressing the immediate concern. However, wider medicines-management gaps remained. These shortfalls increased the risk of people not receiving their medicines safely or when they needed them.

Provider medicines audits recorded 100% compliance but had not identified these shortfalls. There was also limited evidence that medicines errors were consistently reported, investigated and used for learning. This meant the provider’s systems did not provide effective oversight of medicines management or consistently identify opportunities to reduce risks and improve practice.

We received no concerns about the administration of people’s medicines. People and relatives told us they received their medicines on time as prescribed. One relative said, “Medication is provided at regular times with [family member’s] favourite drink and in the same container to prevent confusion.” Another relative told us, “Staff administer all of [family member’s] medicines at relevant times.”