CQC report explained · a residential care home
What the CQC found at Winslow House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, November 2023
Winslow House rated Requires Improvement; inspectors found better safeguarding and health support, but ongoing risks with medicines, care records, recruitment and quality checks.
This was an unannounced focused inspection. Inspectors visited on 13 July and 18 July 2023. They spoke with people, relatives, staff and health and social care professionals. They also reviewed care records, incident records and management audits.
The home had improved since the previous inspection, but inspectors found that important changes were not yet complete or embedded. Medicines were not always managed safely. Care records were incomplete or out of date, and some staff were not confident about managing risks such as diabetes and insulin use.
The home remained in breach of regulations about safe care and treatment, recruitment and good governance. Inspectors also found positive changes, including better safeguarding, falls and weight-loss monitoring, and improved work with health professionals.
The overall rating stayed Requires Improvement. Safe, Effective and Well-led were each rated Requires Improvement. Caring and Responsive were not inspected during this visit, so their previous ratings were used in the overall rating.
Improved safeguarding
Safeguarding procedures were updated and incidents were reported to the appropriate outside agencies. The home was no longer in breach of the safeguarding regulation.
“Staff understood their responsibilities and had reported incidents and involved external agencies as required.” from the report
Health professional support
The home worked with health professionals to manage people's health needs and followed advice. A weekly meeting with the GP surgery and regular health checks were in place.
“Two professionals told us the service referred to them appropriately and had responded well to their advice.” from the report
Better weight monitoring
People's weights were monitored and action was taken when weight loss or gain suggested that extra support was needed.
“Systems for monitoring and responding to weight loss had improved.” from the report
Positive views of care
People and relatives generally said they felt safe and well cared for. People said staff listened to them and managers responded to complaints.
“People and their relatives were positive about the service and told us they felt safe and well cared for.” from the report
Medicines safety
seriousMedicines processes were not always followed. Records and audits did not reliably show that medicines, creams and prescription changes were handled safely.
“People were not always protected from risks associated with medicines as provider processes were not always followed and medicines audits had not identified these shortfalls.” from the report
Diabetes and other risks
seriousCare plans did not contain enough information about diabetes, insulin and constipation. Staff gave different answers about when to act if someone's blood glucose was low.
“The 3 staff we spoke with about managing hypoglycaemia each gave different blood glucose levels they would act upon.” from the report
Incomplete care records
seriousPaper records were not always complete or up to date, and staff did not often use the risk assessments and support plans available to them.
“Paper records were not always complete or up to date; staff rarely referred to people's risk assessments or support plans.” from the report
Recruitment checks
seriousThe provider could not show recruitment records for checking at this inspection. The recruitment policy also did not clearly set out all required checks.
“The provider had not established safe recruitment procedures to ensure staff employed were suitable to support vulnerable adults.” from the report
Quality audits
seriousNew monitoring systems were not yet reliable. Cleaning records had not been completed or audited for several months, and medicines problems had not been identified by audits.
“The provider had failed to operate effective systems to monitor and improve the safety and the quality of the service.” from the report
Waiting at busy times
needs fixingSome people and relatives reported long waits for call bells, help to use the toilet and entry to the building. Managers planned to review call-bell times and staffing needs.
“Feedback from people and relatives suggested staff start times and break times needed review to ensure people's needs were met at busy times.” from the report
- 01How are medicines administration records, handwritten changes, allergies and cream expiry dates checked now?
- 02What specific guidance will staff use when supporting someone with diabetes, insulin or low blood glucose?
- 03Has the new electronic care records system gone live, and how do you check that support plans are complete and up to date?
- 04Can you show how recruitment checks are completed and where the records are kept?
- 05What has changed to reduce waiting times for call bells and help at busy periods?
This was an unannounced focused inspection of Safe, Effective and Well-led, including infection prevention and control; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 11 November 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, April 2023
Rated Requires Improvement; inspectors found kind care and some improvements, but serious gaps in safeguarding, medicines, recruitment and management remained.
This was an unannounced focused inspection on 23, 24 and 26 January 2023. One inspector and an Expert by Experience spoke with people, relatives, staff and health professionals. They also checked care records, incidents, medicines and management records.
People generally said they felt safe. Relatives described trusting the home, and health professionals said staff worked positively with them. Staff supported people with food, healthcare and moving safely. Infection prevention arrangements were also judged satisfactory.
However, inspectors found that safeguarding incidents were not always reported, medicines were not always managed safely, and recruitment checks were not robust. Some risk assessments, care plans and mental capacity records were incomplete or out of date. The home also failed to submit some required notifications to CQC.
The overall rating remained Requires Improvement. Safe, Effective and Well-led were each rated Requires Improvement. Caring and Responsive were not inspected in this visit, so their previous ratings were carried forward.
People felt safe
People generally said they felt safe. Relatives said they trusted the home and felt reassured.
“Despite the shortfalls we identified, people told us they felt safe.” from the report
Good health links
Staff worked with GPs, community nurses and other health professionals. Inspectors found that communication and support for health needs were good.
“The service worked closely with health care professionals to manage people's heath related needs and communication was good.” from the report
Food and dietary support
People had access to a balanced diet, and staff had completed training on textured food and thickened drinks. Inspectors saw food being served carefully and people being given time to eat.
“People had access to a healthy balanced diet and there was a system in the kitchen to support delivery of food in line with people's recorded dietary needs and preferences.” from the report
Pleasant environment
People appeared comfortable in the home. There were communal areas, adapted facilities and an accessible garden.
“People seemed 'at home' at Winslow and looked relaxed and comfortable in the environment.” from the report
Positive atmosphere
People, relatives and staff described a friendly atmosphere. Meetings were held with people and relatives, and some feedback had led to changes.
“People and their relatives were asked for their views about the service at 3 monthly meetings and their feedback was acted upon.” from the report
Safeguarding was not always reported
seriousInspectors found three safeguarding incidents that had not been reported to the local authority. Police had not been informed about a potential theft and an alleged assault.
“We identified 3 safeguarding incidents which had not been reported to the local authority safeguarding team, responsible for investigating concerns of abuse.” from the report
Medicines were not always managed safely
seriousMedicine storage, records and reviews were not always adequate. Some as-required medicines lacked person-specific instructions, and one person received an unprescribed medicine on five occasions.
“The provider had failed to ensure the proper and safe management of medicines.” from the report
Some restrictions lacked legal authorisation
seriousTwo people who could not leave without supervision did not have DoLS applications submitted. Many staff also lacked current Mental Capacity Act and DoLS training.
“The provider had not established systems and processes to ensure people were not deprived of their liberty without lawful authority.” from the report
Recruitment checks were incomplete
seriousThe home did not always obtain evidence about conduct in previous care roles or verify why applicants had left previous employment. Inspectors said this could put people at risk of unsuitable staff being employed.
“The provider had not established safe recruitment procedures to ensure staff employed were suitable to support vulnerable adults.” from the report
Records did not always reflect people's needs
needs fixingSome nutritional and other risk assessments were inaccurate or not updated when people's needs changed. Care plans did not always give staff enough detail to manage health risks.
“Records did not always contain up to date information about the care people required.” from the report
- 01Have all safeguarding incidents now been reported to the local authority and police where needed?
- 02How have medicines storage, administration records and as-required medicine instructions been checked since the inspection?
- 03Have DoLS applications been submitted for everyone who may be deprived of their liberty, and how are existing applications followed up?
- 04How do you now check conduct and reasons for leaving in previous care jobs before recruiting staff?
- 05What evidence can you show that the new quality monitoring system identifies and fixes problems promptly?
This was a focused inspection of Safe, Effective and Well-led, including infection prevention and control; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 1 April 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.
Every inspection of Winslow House
6 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- November 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2023Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- December 2021Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- January 2020Goodstayed GoodSafe: GoodEffective: GoodWell-led: Requires improvement
- May 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- April 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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Most charge £1,030 to £1,360 a week. 31 can care for a couple. 12 years' experience on average.
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