Wyndham House Care

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 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

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. Lessons were not learnt to continually identify and embed good practice. We found accidents, incidents and concerns were recorded, but these did not always translate into actions to prevent further harm. We found people’s care plans were not updated in line with risks identified. One person was noted to display distressed behaviours; however, they did not have a behaviour support plan, and consequently, no strategy to support them consistently. Staff told us they did not always get feedback from reported incidents, which sometimes left them confused about whether anything had changed. We received mixed feedback from relatives. Most relatives felt people were safe, but learning from incidents was not always shared. One relative told us, “They [relative] have been in hospital because they fell, but I have not been told how that happened.”

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 were in place for people, and although these had been reviewed just prior to the inspection, they contained inconsistent information about people. The provider had several systems for collecting data; however, these did not translate into meaningful action plans. We found that where referrals had been made for people, their care plans were not updated with the outcome or updates of ongoing referrals.

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. For example, one person’s care plan required them to be repositioned every four hours, as they were at risk of developing pressure sores. However, we found this was hardly ever met, with days where the person was not repositioned for over 8 hours. Given the person’s identified risks , the provider had not analysed and acted on the data collected daily. Mental Capacity assessments had not been completed in line with the Mental Capacity Act 2005. People had not been involved in the capacity assessments, and the provider did not record the rationale or best interest decisions. The provider had submitted Deprivation of Liberty Safeguards (DOls) applications for people who needed one, and some had been approved. This meant the provider was working in line with expectations.

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. Some people had health conditions and support needs that increased their risk of harm. The provider did not ensure adequate risk assessment and management plans were in place for staff to safely manage these conditions. One person was prescribed medication for pain management. However, the provider had not provided staff with any direction on how to identify the person was in pain. We could not see that the provider used a pain management tool to manage pain effectively.

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 found that although there had been 48 recorded falls in November and December 2025, there were trip hazards all over the home. Wet floor signs were left in bedrooms and around the home, for hours after the floors were dry. We found trailing cables within bedrooms, and a fire exit had been obstructed by old carpets that had been taken off during refurbishment. We found the location had uneven surfaces and sloped corridors, but there were no grab rails to support people whom we observed walking unsupervised. Issues which had been identified during the Local Authority’s Provider Assessment and Market Management Solution (PAMMS) a year earlier had not been rectified.

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. We found there was not enough staff to meet people’s needs, and people hardly had a shower. One relative told us, “Personally I would like to see more [staff]; they are quite thinly stretched in regard to staffing levels”. The Provider had an over-reliance on agency staff. At the time of inspection, 48% of all shifts were covered by agency staff, but we found that the provider had not completed the relevant compliance checks on the staff and the staff had not completed, essential training required to support people. We raised this with the provider, and they began taking corrective action. The agency staff did not respond to people’s needs effectively and were mostly task focused. We saw some good care and communication between permanent staff and the people they supported.

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. We found that bedrooms were routinely cleaned, and there was a dedicated laundry team. However, staff, both support staff and laundry staff, told us the location went through a shortage of incontinence pads for 3 weeks, resulting in people being left in soiled clothing and towels being used. The provider, while admitting there had been a shortage, insisted it lasted days, not weeks. However, we could not see the provider had reported the incident or carried out a comprehensive review. We did not see an action plan to prevent future shortages. Care plans contained no clear procedures around the management of infection and pressure ulcers. We found tables were not cleaned after meals, and some of the side tables had dried food. Most of the relatives we spoke to feel the cleanliness was ok.

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. We found people’s care plans did not include information on the medication they were prescribed or on health conditions that were mentioned in other parts of the care plans. The provider did not have clear procedures for auditing medication returned from the hospital leading to missed medication. For example, a person returned to the location from hospital, and it was discovered 5 days later that they had missed 3 of their medicines in that time, despite the requirement for daily audit by staff dispensing medication. The provider relied on agency senior staff to dispense medication, but we could not see that the provider carried out regular medication competencies with these staff.