West Wood 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 the legal regulation in relation to safe care and treatment. We identified concerns and shortfalls regarding assessing risks to people’s health care and safety, staffing levels and medicines management.

This service scored 38 (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 always investigate or report safety events appropriately. Lessons were not learnt to continually identify and embed good practice.

We found evidence of a blame culture with the manager and senior management team. When shortfalls were identified or concerns raised, they were defensive and quick to lay blame with staff, people using the service or their representatives. Records of lessons learned were weak and staff were quickly disciplined as a means of ‘lessons learned’ rather than being supported to learn from mistakes and improve practice.

For example, it was identified during an audit that staff had given a person’s nutritional supplement from another person’s supply. A ‘5 minute’ lessons learnt meeting was called and the lesson learnt was stated as being, “Please make sure the correct medication is being given to the allocated resident. You should never share residents’ medication. Ever.”

Another incident showed the lesson learned from an identified shortfall as being letters of concern and oral warnings given to staff members.

A person’s representative told us their relative had recently experienced 2 falls. They explained how 1 fall had been deemed the fault of the carer, who was subsequently dismissed.

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 noted that a person had moved to West Wood from a different service, owned by the same provider. However, when we reviewed their pre-admission assessment, care plan and risk assessment, we found these contained very limited information about the person’s specific needs. Some of the information we read was contradictory and there was no clear handover from 1 service to the other.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always 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 always share concerns quickly and appropriately.

Staff and management did not always recognise or understand potential signs of abuse or neglect and some staff told us they were afraid to speak up in case they lost their jobs.

Staff and people’s representatives told us there were not always enough care staff on duty to safely and appropriately support the number of people living in the home and the provider did not recognise the impact this had on people.

A member of staff told us, “The lack of staff means that residents are often ringing call bells and are not able to be helped for long periods of time.”

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 living in the home had generic templates for risk assessments, as part of the electronic care planning system, which covered most aspects of their daily lives. However, we saw that some risk assessments were not in place where risks had been identified and, in some cases, staff did not act in line with the guidance stated within people’s risk assessments.

For example, a person’s medicines administration records (MAR) stated they were allergic to shellfish and fish, as well as certain medicines. However, the person’s care plans and risk assessments did not contain any information regarding the allergies to shellfish and fish. We saw it recorded that this person had fish pie for their lunch on 19 November 2025. Although they did not appear to have experienced any ill effects from this, it put the person at risk of harm, because not all staff were aware of the recorded allergies and there was no risk assessment in place.

The electronic system being used to record and store people’s risk assessments was cumbersome and unreliable. Many areas were difficult to make sense of and some were contradictory. It was apparent that not all staff completing the records on the electronic system had been trained or understood how to complete the information correctly.

For example, in the section headed, ‘Waterlow’ (the Waterlow scale is a risk assessment tool designed to calculate an individual's risk of developing pressure ulcers.) a person’s risk assessment stated that they were chair/wheelchair bound. However, on other pages, information described how they walked with a frame.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The premises had been newly built in 2024 and, overall, it appeared to be well maintained. However, we identified some shortfalls in respect of appropriate facilities and technology.

On 2 December 2025, staff on the Memory Care Floor logged us into a tablet but informed us that we would not be able to review people’s care records whilst in the dining room, as there was no WiFi signal there. We found this was the case and needed to resume reviewing the care records whilst seated at the care station, after the senior had logged us back in again. We were subsequently concerned that this contributed to staff not reviewing or completing records in real time.

Following this assessment, the provider told us that the Memory Care Floor had since had its WiFi coverage strengthened to ensure consistent access across all areas. In addition, the provider assured us that it was possible to use the electronic care system without a WiFi signal, as it had offline capabilities. They explained that these offline capabilities helped ensure continuity of care in areas with poor or no connectivity, because care staff could still document care in real-time and the information would synchronise with the main server once a connection was re-established.

However, we were not assured that all staff understood the offline capabilities of the electronic care system, as we found multiple examples of care records and tasks being completed retrospectively.

We were concerned, following feedback from some people’s representatives, that people’s choices and preferences were not always listened to regarding the layout and facilities within the home. For example, a person’s representative told us “[Name] enjoys some of the activities and I have seen the odd puzzle being done but, as there is no table big enough to accommodate it, it is packed up without being finished. If there was a puzzle table, different people could add to it at different times. I think they are missing something here.” The provider told us that, if people needed a bigger table for activities, 2 tables could be put together to provide this facility.

Another person’s representative told us their relative had a double bed in their room, which they said meant there was very little space for them to move around in. The representative told us they had asked to replace the double bed with their relative’s own single bed from home. However, they were told this was not possible. The provider told us that all bedrooms exceeded the minimum standard size and gave us photographs and a floor plan, which showed that the bedrooms were all of a good size and should comfortably accommodate a double bed. However, we were not assured that people were able to make changes to their personal spaces to meet their individual choices and preferences.

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.

For example, there were insufficient staff deployed to support and interact with people living on the first floor ‘Memory Unit’, to help ensure the dining experience was a positive, pleasurable and stimulating one.

During the main lunch period on 2 December 2025, we saw 3 members of staff were in the vicinity. However, 1 member of staff was collecting and delivering meals to people in their rooms, so did not remain in the dining room. The senior was administering people’s medicines, whilst the wellbeing coordinator confirmed people’s choices and served the meals.

While people were eating their main courses, the wellbeing coordinator answered a telephone call and needed to go downstairs. The senior said they would be okay to cover in their absence. However, this meant the medication round was interrupted and we saw there were many occasions where there were no staff in the dining room at all. There were 11 service users and 3 relatives eating at 5 separate tables.

At the commencement of our inspection there were 30 people living in the home, with virtually the same number of people living on each floor.

The manager told us the night shifts had a minimum of a senior, plus a member of care staff on each floor. However, we saw from the rotas that there were many occasions when a total of only 3 staff had been on duty to cover both floors, with only 1 senior. There were also occasions when no senior cover had been available to cover the waking night duty. The manager told us that, on those occasions, senior staff had covered by way of sleep-in shifts.

We looked at the call bell audit from 16 to 30 October 2025 and analysed the log for the night shift from 8pm on 18 October 2025 through to 8am on 19 October. We saw the call bells had been activated 70 times on the ground floor by 10 different people and 50 times on the 1st floor by 5 different people. We saw this was not an unusually busy night and, on this occasion, there had been 2 staff on each floor. We were also aware that some people required support but were unable to activate their call bells and some people required 2 staff for support. In addition, consideration needed to be given to ensuring staff had adequate rest periods during their 12-hour shifts.

All the evidence we reviewed showed that some staff had regularly worked in excess of 70 hours per week. We saw that 7 members of staff were scheduled to work for 60 hours or more on some weeks during December 2025, including 2 members of staff who were scheduled on the rota to work 85.75 hours in the 1st week of December 2025.

This demonstrated a lack oversight by the senior management and also posed a risk to the health, safety and wellbeing of people using the service, as well as the care staff.

People’s representatives also told us they felt the home was often short staffed. Their comments included, “They are often short-staffed, even during the day at times as I tend to visit between 9am and 6pm. You do hear call bells going off quite a bit too.” “I have even heard staff saying they are short-staffed and are doing their best.” “There have been quite a few times when I have noticed that agency staff have boosted the carer numbers. They don’t always know everything that the others know [about people living in the home].” And, “The caring has been a bit ad-hoc simply because of staffing levels and agency staff being used to fill the gaps.”

The poor management and oversight of staff deployment and the frequent insufficient numbers of suitably qualified, competent, skilled and experienced staff, particularly during the night shifts, placed people at risk of discomfort, harm and neglect.

The provider did not always assess or manage the risk of infection and they did not always detect and control the risk of it spreading.

On 19 November 2025, the entire premises appeared clean and fresh, with no unpleasant odours. However, on 2 December 2025, there were noticeably strong odours of urine in the dining room by the Christmas tree and in the corridor, particularly near the carers’ station.

A person’s relative also raised this with us and said they had noticed a strong and unpleasant odour of urine during each of their visits over the past week.

On 2 December 2025 a person’s representative told us, and we observed, that the dining room tables and floor had not been properly cleaned before people entered the dining room and sat down for their lunch. Some tables were sticky and had remnants of food on them, the floor felt sticky underfoot and also had food debris.

However, some people did make positive comments such as, “The whole place is kept very clean actually. It’s more like a hotel than a care home.”

The provider failed to ensure the proper and safe management of medicines and best practice guidance was not consistently adhered to. This was because people were not always receiving their medicines as prescribed.

During our site visit on 19 November 2025, we observed that people living on the 1st floor (Memory Floor) were not administered their lunchtime medicines until after the lunch period, which was after 2.30pm. A member of staff told us they did not like to disturb people while they were having their lunch and so they usually administered these afterwards. However, during our second site visit on 2 December 2025, we observed a different member of staff administering people’s lunchtime medicines to them while they were seated in the dining room from approximately 12.30pm.

We were concerned about the variances in the times that people were being given their medicines, particularly as some medicines need to be given on time and some need a gap of at least 4 hours between doses.

We looked at 8 people’s medicines administration records for November 2025 and saw that, although the electronic system had pre-set times for when people should receive their prescribed medicines, the actual times of administration could be completely different and it would not be possible to monitor or audit this.

For example, on 19 November 2025 we observed a member of staff administering a person’s time sensitive medicine after 2.30pm. However, the medicines administration record for 19 November showed that this medicine had been administered at 12pm. The NICE guidance states that people who are prescribed this particular medicine, should take it within 30 minutes of their individually prescribed administration time. The NICE rationale states that serious complications can develop if this medicine is not taken on time. These include acute akinesia and, if delays are significant, neuroleptic malignant syndrome. These complications can lead to increased care needs. Our observations showed that this medicine had not been administered within the required time range on 19 November 2025.

Some people’s representatives also told us there had been issues with their relatives’ medicines.

For example, a person’s representative told us that a lot of medicines had been taken to the home upon their relative’s admission and were “understandably” taken away for entering into the home’s computer system. However, this person went on to say, “We were then advised some had been thrown away as they were out of date, while others were not available for a while. It was eventually sorted, but not without some concern for my parent’s health.”

Another person’s representative told us, “Recently a paramedic prescribed something for conjunctivitis, but the meds never arrived.”

However, a further person’s representative told us, “I have noticed the senior carer doing the medication round and they wear their red tabard and staff know not to disturb them.”