CQC report explained · a nursing home
What the CQC found at Winifred Dell Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Risk assessments, safeguarding systems and falls monitoring were in place, although staff deployment was not always consistent and a minor medicine recording error was found.
- Effective?
- Good
- The report does not give a current rating for Effective.
- Caring?
- Good
- The report does not give a current rating for Caring. People and relatives spoken to were generally positive about the support.
- Responsive?
- Good
- The report does not give a current rating for Responsive.
- Well-led?
- Good
- Managers and the provider had audits and monitoring systems, acted on the issues found and involved people, relatives and staff in giving feedback.
What inspectors found, September 2023
Winifred Dell Care Home rated Good; inspectors found safe, well-managed care, but staff deployment and medicine records needed improvement.
This was an unannounced inspection on 23 August, 25 August and 1 September 2023. Inspectors looked at concerns about unwitnessed falls. They spoke with people, relatives, staff and a health professional, observed care, and checked care, medicine and staff records.
The home was rated Good overall, with Good ratings for Safe and Well-led. Inspectors found risk assessments, safeguarding arrangements and accident monitoring in place. They found no evidence that people were at risk of harm from the concerns about unwitnessed falls.
There were some shortfalls. On one day, staff did not always supervise communal areas well, and one person waited a long time for help. There was also a medicine recording error. The managers acted after the inspection by reviewing staff skills, adding oversight and speaking with staff about the issues.
Risk management
The home had detailed assessments for risks such as falls, moving and handling, nutrition and skin integrity. Environmental safety systems were also maintained.
“Staff undertook risk assessments to keep people safe.” from the report
Learning from falls
The home had identified unwitnessed falls and was using an action plan, including discussions at every handover and reviews of equipment and activities.
“A falls prevention action plan was in place which included various initiatives to try to further reduce falls” from the report
Management oversight
The provider and senior team carried out audits across several areas and followed up shortfalls until they were addressed.
“The provider and the senior team undertook a range of quality audits to identify where improvements could be made.” from the report
Positive experience
People and relatives generally spoke positively about the home. Inspectors also saw people interacting, taking part in activities and enjoying a lively atmosphere.
“People and relatives were positive about the service.” from the report
Staff supervision
seriousOn the first inspection day, staff were not always available to supervise people in communal areas. One person at high risk of falling stood without their walking aid, and another waited a long time for help. Managers put extra measures in place afterwards.
“One person in the service was a high risk of falling and continued to stand without their mobility aid.” from the report
Medicine recording
needs fixingA medicine recording error was found after a refusal had been recorded incorrectly. Managers dealt with it immediately, but inspectors also said more personalised guidance would help with some medicines given when needed.
“The deputy manager quickly identified this was a recording error related to a refusal of a medicine which had been signed for” from the report
- 01How do you now make sure staff are deployed consistently in communal areas?
- 02What extra supervision is provided for people at high risk of falls?
- 03How are medicine refusals checked and recorded correctly?
- 04What personalised guidance is available for medicines given when needed?
- 05How do your audits check that the changes made after this inspection are working?
This was an unannounced inspection focused on Safe and Well-led, prompted in part by concerns about unwitnessed falls; the report gives no current ratings for the other three questions. This explanation was written from the published report of 20 September 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, January 2020
Winifred Dell Care Home was rated Good; inspectors found kind, personalised care, but identified a staffing shortfall on the top floors.
This was an unannounced inspection on 26 November 2019. Inspectors spoke with people living at the home, relatives, staff and managers. They observed care and checked care, medicine, staff and management records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People and relatives generally described the care as safe, kind and well organised. Medicines were managed safely, people's health needs were monitored, and care plans were detailed and personalised.
Inspectors found a staffing shortfall on the top floors. Accidents and incidents suggested staff were not deployed effectively enough in that area, increasing the risk of harm. The manager had already identified this and added a staff member to the rota on the day of the inspection. Inspectors also noted limited one-to-one activities and an activity notice that was difficult for some people to read.
Kind and respectful care
People and relatives spoke positively about the staff. Inspectors saw reassurance, encouragement, respect for privacy and support for people's independence.
“People felt safe and well cared for by kind caring staff who often went the extra mile to meet people's needs and wishes.” from the report
Dementia-friendly environment
The upstairs dementia areas had been refurbished with activities, visual features and spaces designed to encourage exploration, stimulation and reminiscence.
“An excellent feature of the service was the thought and consideration given to the design and decoration of the two dementia units” from the report
Personalised care
Care plans included people's histories, strengths, routines, likes and dislikes. People and their representatives were involved in reviewing their care.
“Care plans were recorded electronically and were of a very good quality.” from the report
Strong management oversight
Managers were described as approachable and visible. The home used regular audits, meetings and feedback to identify concerns and improvements.
“The safety and quality of the service was monitored and assessed consistently by the management team and provider.” from the report
Staffing on the top floors
seriousInspectors found that staffing numbers needed to increase on the top floors. Accidents and incidents suggested staff were not deployed effectively enough, increasing the risk of harm. An additional staff member was added to the rota on the inspection day.
“Staffing numbers needed to increase on the top floors.” from the report
Limited individual activities
needs fixingPeople who could not or did not want to join the group activity did not have other activities available at the time. Staff also said they did not always have enough time for one-to-one support.
“We did note for people who were unable or did not want to join in the group activity, there was no other activities made available for them.” from the report
Activity information was hard to read
minorThe activity planner was written in very small print, making it difficult for some people to read. Managers said a large-print version would be used on the notice board.
“the activity planner on the notice board which was written in a very small font, making it difficult for some people to read.” from the report
Oral health training
minorStaff had not yet received formal training in oral health care. The manager said this was planned.
“Staff had not yet received formal training in oral health care, but the registered manager told us this was planned.” from the report
- 01What staffing levels are now provided on the top floors, and how do you check that staff are deployed safely there?
- 02Have there been any further accidents or incidents on the top floors since the inspection, and what has changed as a result?
- 03What one-to-one or small-group activities are available for people who cannot or do not want to join group activities?
- 04Has the activity information been changed to a large-print format throughout the home?
- 05Have staff now received the planned formal training in oral health care?
This was an unannounced inspection covering all five CQC questions, including the premises and the care provided; all five ratings were given as Good. This explanation was written from the published report of 18 January 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Winifred Dell Care Home
4 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- September 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2020Goodstayed GoodSafe: GoodWell-led: Good
- May 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 24 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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