CQC report explained · a nursing home
What the CQC found at Winscombe Hall
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found sufficient staff, safe recruitment, appropriate risk assessments, safe medicines management and good infection control. They found no evidence that the concerns raised before the inspection had placed people at risk of harm.
- Effective?
- Good
- This area was not inspected during this visit. Its previous rating was carried forward.
- Caring?
- Good
- This area was not inspected during this visit. Its previous rating was carried forward.
- Responsive?
- Good
- This area was not inspected during this visit. Its previous rating was carried forward.
- Well-led?
- Good
- Inspectors found positive leadership, effective audits and an action plan for improvement. This rating improved from Requires improvement at the previous inspection.
What inspectors found, February 2023
Rated Good overall; inspectors found safe care and improving leadership, but some management arrangements and staff development were still being completed.
This was an unannounced, focused inspection on 12 January 2023. Inspectors looked only at Safe and Well-led because concerns had been raised about staffing, management, medicines, continence care and hygiene. They spoke with people, staff and relatives and checked care, medicines, recruitment and management records.
The home was rated Good for Safe. Inspectors found enough staff, safe recruitment, suitable risk assessments, safe medicines practice and good infection control. People appeared comfortable and staff knew their needs. They found no evidence that the concerns raised before the inspection had put people at risk of harm.
The home was rated Good for Well-led. Leadership had changed recently, and the new manager had started an action plan and improvements. Governance checks and audits were in place. The Well-led rating improved from Requires improvement at the previous inspection in 2018.
The overall rating was Good. The other three areas, Effective, Caring and Responsive, were not inspected this time. Their previous ratings were carried forward to calculate the overall rating.
People felt safe
People appeared relaxed and comfortable. Relatives said staff knew people well and understood how to protect them from harm.
“People looked relaxed and comfortable with the staff who supported them. They told us they felt safe living at Winscombe Hall.” from the report
Safe staffing
Inspectors found enough staff to meet people's needs. Staff had a range of skills and experience, and recruitment checks were completed before people started work.
“We found people were supported by sufficient staff to meet their needs.” from the report
Medicines were managed safely
Medicines records and stock checks were accurate. Nurses administering medicines were trained and competent, and regular audits were carried out.
“We found medicines were managed safely and in line with national guidance.” from the report
Improving leadership
The new manager had begun making changes, supported an open culture and used audits and action plans to monitor improvements.
“Effective governance processes were in place and the quality and safety of the service was monitored.” from the report
Clean environment and infection control
Inspectors found the home clean, tidy and free from odours. They were assured that infection risks were being managed.
“We could access all areas of the home and found the premises to be clean, tidy and free of odours.” from the report
No registered manager yet
needs fixingThere was no registered manager in post at the inspection. A new manager had been in post for three months and planned to apply after probation.
“At the time of our inspection there was not a registered manager in post.” from the report
Medicines rounds could take a long time
minorThe manager and staff recognised that medicines rounds could be lengthy. Procedures were being reviewed and changes were underway.
“Staff and the manager agreed the medicines round could take a long time, but procedures had been reviewed and changes were underway to improve this.” from the report
Some staff development was still being updated
needs fixingStaff training, supervision and appraisal records were being monitored, but plans were still in place to bring some of them up to date.
“Plans were in place to ensure these were all brought up to date.” from the report
Communication was not yet consistent
minorMost feedback about the new manager was positive, but one relative felt communication had not improved as much as hoped.
“One relative felt communication had not yet improved as much as they hoped with the new manager.” from the report
- 01Has the manager now applied to become registered, and what is the current position?
- 02What changes have been made to reduce the time taken for medicines rounds?
- 03Have all staff supervisions, appraisals and refresher training been brought up to date?
- 04How do you check that communication with relatives is prompt and consistent?
- 05What are the current ratings and evidence for Effective, Caring and Responsive, which were not assessed in this inspection?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous inspection in 2018. This explanation was written from the published report of 15 February 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, June 2018
Rated Good and out of Special Measures; inspectors found safe, kind care, but the home was still Requires Improvement for being well-led.
Inspectors visited the home without notice on 9 and 10 May 2018. They spoke with people living there, relatives, staff and health professionals. They reviewed care records, medicines, staff files, complaints, accidents and management checks.
The home had made significant improvements since the previous inspection. Inspectors found safer medicines management, better risk assessments, enough staff, improved training and more complete care records. People were treated with kindness and respect, and relatives were positive about the care.
The overall rating was Good. Safe, Effective, Caring and Responsive were all rated Good. Well-led was rated Requires Improvement because the home needed more time to show that its improvements could be maintained, especially if the number of people living there increased.
The home had been in Special Measures since June 2017 and had previously been rated Inadequate in at least one area. It was taken out of Special Measures after this inspection. Inspectors found no breaches of the regulations at this inspection.
Safer care
Risk assessments and care instructions had become much more detailed. Staff supported people safely with transfers and other identified risks.
“People's care records now contained comprehensive assessments of risks to their health and well-being and guidance for staff on how to manage these risks.” from the report
Safe medicines
Medicines were stored, given and recorded safely. Staff used clear instructions and pain assessments where needed.
“We found that people now received their medicines safely.” from the report
Personalised care plans
Care records included people's life histories, preferences and detailed instructions about how care should be given. Plans were reviewed when needs changed.
“Care plans were comprehensive and person centred. They contained clear information about people's care needs and preferences.” from the report
Improvements need to last
needs fixingThe home had improved, but inspectors wanted more time to see that the changes would continue. They were also concerned about whether safe, good quality care could be maintained if occupancy increased.
“However, further time is needed as the provider needs to demonstrate these improvements can be maintained.” from the report
Limited activities
needs fixingInspectors saw one activity, but felt there were not always enough activities. There was no record of activities for people who stayed in their rooms.
“However, we felt that activities were limited and there was no record of activities provided for people who stayed in their rooms.” from the report
Spiritual support
minorPeople's religious details and burial wishes were recorded, but the home did not provide religious or spiritual support.
“There was no provision for people to receive religious or spiritual support.” from the report
Significant vacancies
needs fixingThe home had a significant number of vacant places. Inspectors wanted the provider to show that care would remain safe and good quality if more people moved in.
“The home has a significant number of vacancies and the provider needs to demonstrate that safe, good quality care can be provided when the numbers of people accommodated increases.” from the report
- 01What activities are available for people who prefer to stay in their rooms, and how are these activities recorded?
- 02How can residents receive religious or spiritual support if they want it?
- 03What evidence shows that the improvements in management and quality checks are being maintained?
- 04How will staffing and care quality be protected if more people move into the home?
- 05How are fluid intake records checked to make sure people's daily targets are met?
This was an unannounced comprehensive inspection covering all five key questions, following the home's previous time in Special Measures and earlier breaches. This explanation was written from the published report of 21 June 2018 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 Winscombe Hall
6 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- February 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2018Goodup from InadequateSafe: GoodWell-led: Requires improvement
- November 2017Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- June 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 7 January 2011.
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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23 live-in carers within about an hour of North Somerset
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,050 to £1,320 a week. 19 can care for a couple. 12 years' experience on average.
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