Wayside 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 requires improvement. At this assessment the rating has changed to inadequate.

This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to safe care and treatment and safe environment.

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 investigate or report safety events in a timely way. Lessons were not learnt to continually identify and embed good practice.

The provider did not demonstrate a proactive or positive culture of safety based on openness and honesty. Known risks, including fire safety concerns, poor infection prevention and control and unsafe practices, were not identified investigated or responded to in a timely way. Governance systems, including audits and reporting processes, were ineffective, resulting in concerns not being consistently escalated. There was limited evidence of learning from incidents or embedding improvements, with repeated issues observed throughout the inspection.

Previous concerns identified to the provider from past inspections had not always been effectively acted on. For example, during our last inspection published in September 2025 we reported concerns regarding the effective evacuation procedures in the event of an emergency. At this inspection there were still significant concerns regarding this which we escalated to the fire service for their attention. The providers failure to have effective and proactive systems in place for learning put people at the risk of harm from avoidable incidents.

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. For example, we saw an instance where 1 person’s speech and language recommendations could not be located. There was no evidence the provider had acted to locate the missing information or reestablish an accurate and up to date assessment from a partner agency. There were gaps in communication and follow-through on recommendations from external professionals, and key assessments were not always accessible or embedded into care planning. For example, there were sections of peoples care plans where key information was missing. If people were to move between services, the information about them was incomplete and in some instance inaccurate and missing. This meant professionals wouldn’t always have the full picture, which could disrupt the continuity of care and increase the risk of inconsistent care.

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. Systems to safeguard people from harm were not always effective. Although staff demonstrated some understanding of safeguarding, the provider had failed to notify safeguarding concerns appropriately, and risks to people were not consistently managed. One member of the management team stated they were unclear about reporting thresholds and needed to seek advice from safeguarding, indicating inconsistent understanding of abuse and the reporting requirements.

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. The provider was not consistently meeting the principles of the Mental Capacity Act. There was some evidence of compliance in specific areas (e.g. DoLS applications and some decision-making processes), but this was inconsistent and undermined by poor record keeping, lack of clarity, and failure to implement conditions or ensure person-centred decision-making. For example, DoLS conditions for 1 person required support to access communal areas and recording activities and interactions. However, records did not demonstrate these conditions were consistently followed as the provider could not demonstrate legal safeguards were in place.

The provider did not 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 were not consistently involved in identifying and managing risks. Risk assessments often lacked people specific information, were generic or missing entirely, particularly in relation to significant risks such as the use of the lift. There was a lack of understanding or assessment regarding the emotional impact of being supported in an environment which was unsafe and potentially isolating. For example, people were being put into the lift and left as the staff member went up the stairs without explanation or support for the person left alone in the lift. There was a lack of understanding by the provider regarding staff members having to resort to unsafe working practices to attempt to support people owing to environmental restrictions. For example, there was no mitigation should a person fall against the concertina doors preventing access to the lift. There was a lack of evidence of updated risk assessments or learning to prevent recurrence, placing people at continued risk. For example, the provider was not able to demonstrate they had assessed and mitigated risks regarding the use of the lift.

The provider did not always detect and control potential risks in the care environment. They did not make sure equipment and facilities supported the delivery of safe care. The environment was not safe and posed significant risks to people.

Inspectors identified multiple serious concerns of which fire safety was of particular concern. There were blocked fire exits and inadequate evacuation routes, coded locks which did not automatically open in the event of an emergency and the codes not known or easily accessible to staff. These issues put people at the risk of harm in the event of a fire. People were exposed to hot water pipes and the boiler systems putting them at the risk of burns, there were exposed fixtures including staples in furniture which put people at the risk of penetrative injury, not all window openings were restricted putting people at the risk of falls from height. The premises had only 1 operatable lift to move people between floors. This was smaller than the recommended accessible standards and we saw multiple instances where staff members were using unsafe practices to support people owing to the environmental limitations of the lift design. This put people at the risk of avoidable harm when using this part of the building. The premises did not support safe care and put people at the risk of avoidable harm.

The provider did not always 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 always work together well to provide safe care that met people’s individual needs. A staff member had been employed without detailing a full employment history and there were still gaps in the employment history which did not support a safe recruitment process.

There were inconsistent practices in staffing and staff competency. While staffing numbers were reported as sufficient, inspectors observed unsafe moving and handling practices, particularly in relation to the use of the lift and wheelchair support. The provider was not managing staff members operational competencies or addressing unsafe behaviour putting people at the risk of harm. There were also gaps in training records, including fire evacuation training and people could not be assured they would be supported in the event of an emergency by competent and trained staff.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading. Infection prevention and control systems were ineffective. High-touch surfaces were worn, damaged and not cleanable, increasing the risk of infection transmission. The provider had not effectively managed Legionella risks, with unclear action plans and incomplete monitoring systems, which posed a significant risk to people’s health. Areas of the of the home displayed evidence or water egress and in some instances, water was free flowing down a wall with compromised and blown plaster finishes. We saw people eating meals from tables which were poorly maintained with excessive bobbling of the surface and missing edges in some instances. Some bins for the use of clinical waste were poorly marked or broken. These issues hampered effective cleaning practices putting people at the risk of avoidable harm.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. Medicines were generally managed safely, with some evidence of good practice observed. Staff followed appropriate administration processes, communicated with people effectively, and ensured medicines were taken safely. However, governance systems underpinning medicines management were not effective, with gaps in the audits completed and the management oversight.There was limited assurance audits systems would be effective in identifying when errors had been made in the administration of medicines.