CQC report explained · a residential care home
What the CQC found at Winterfell Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2022
Rated Requires Improvement; inspectors found safety risks, weak checks and incomplete records, with warning notices issued.
This was an unannounced focused inspection on 20 and 21 September 2022. Inspectors looked at Safe and Well-led. They spoke with people, relatives and staff, and reviewed care records, staff files and management records.
The home was not always safe. Inspectors found risks from windows, trip hazards, radiators, fire doors and sharp items. Some equipment used to help people move was unsafe. Recruitment checks and safety audits were also incomplete.
There were some positive findings. People were protected from abuse, medicines were given safely, infection controls were in place and lessons were learnt from accidents. Staff were supported and worked with outside professionals, but relatives gave mixed views about communication.
The overall rating fell from Good to Requires Improvement. The Safe and Well-led ratings were Requires Improvement. The other key question ratings were carried forward from the previous inspection because this inspection did not assess them.
Safeguarding
People were protected from abuse. Staff knew how to report concerns, and the home investigated safeguarding matters and took action to reduce future risks.
“People were protected from the risk of abuse.” from the report
Medicines
The home had medicines profiles, trained staff, safe storage and regular checks of medicines practice.
“People received their medicines safely.” from the report
Learning from incidents
Managers reviewed accidents and incidents, looked for patterns and recorded actions to reduce the risk of them happening again.
“Lessons were learnt following incidents and accidents.” from the report
Staff support
Team meetings and regular supervision were in place. Staff told inspectors they felt supported by managers.
“Team meetings were held, and staff received regular supervisions from managers.” from the report
Environmental safety
seriousInspectors found several risks, including missing or broken window restrictors, uncovered radiators, unsafe fire doors, trip hazards and sharp items. Some issues were dealt with during the inspection, but they had not been identified or controlled beforehand.
“The provider did not always mitigate environmental risks such as windows, trip hazards, radiators, fire safety, and items that could injure people.” from the report
Unsafe equipment
seriousA sling that should have been discarded was being used to help someone move. It was removed during the inspection.
“We found a person had been receiving support to mobilise in a sling no longer safe for use and should have been discarded.” from the report
Incomplete checks and records
needs fixingManagers' safety audits did not always match what inspectors found. Some care plans and staff records were incomplete or out of date.
“Safety checks and audits carried out by managers were not always completed accurately.” from the report
Recruitment checks
needs fixingSome staff files did not contain verified references, enough employment history, right-to-work evidence or up-to-date DBS information.
“Staff were not always recruited safely.” from the report
Communication with relatives
minorRelatives gave mixed feedback. Some said communication was good, while others said they were not kept informed, including about a hospital visit.
“We received mixed feedback about how well the service communicated with relatives;” from the report
- 01What has been done to permanently fix the window, radiator, fire door and trip hazards identified by inspectors?
- 02How do you now check that hoists, slings and other moving equipment are safe before they are used?
- 03Have all staff files been updated with verified references, right-to-work documents and current DBS information?
- 04How are care plans checked and updated after a person's needs or risks change?
- 05How will you make sure relatives are told promptly about hospital visits and other important events?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried forward from the previous inspection published on 9 March 2022. This explanation was written from the published report of 25 October 2022 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, March 2021
Winterfell Care Home is rated Good; inspectors found safe care and stronger management, and it is no longer in Special Measures.
The inspection was unannounced and took place on 11 February 2021. Three inspectors visited the home, spoke with people, relatives and staff, observed care, and reviewed care, medicines, recruitment and management records.
The inspectors rated Safe and Well-led as Good. They found that people's risks and health needs were recorded, staffing was safe, medicines were generally managed safely, and infection control arrangements were in place. They also found that managers were monitoring the service and acting on problems.
This was a follow-up after the home was rated Inadequate in October 2020 and placed in Special Measures. The home had previously breached several regulations, but the inspectors found enough improvement for those breaches to end. The overall rating changed to Good, and the home left Special Measures.
The inspection was prompted partly by a serious incident involving an injury. The report says the circumstances of that incident were not examined because it may be subject to a criminal investigation.
Detailed risk planning
Care records described people's physical and mental health risks in detail and explained how staff should support them.
“Care records were person centred and contained extensive and detailed assessment of people's physical and mental health risks with detailed measures in place on how to support people.” from the report
Safe staffing
Staffing numbers were based on people's needs. Inspectors saw staff providing calm, caring and unhurried support.
“Staffing levels were safe. Staffing numbers were calculated using a detailed dependency tool which identified people's specific needs and support required to care for people safely.” from the report
Improved management
Managers used audits, action plans and daily checks to monitor safety and care standards. They had also improved how incidents were analysed.
“Monitoring systems were in place to check the quality of the service.” from the report
Medicines generally managed safely
Medicines were stored securely, administration records were up to date and staff had regular competency checks.
“Medicines were managed safely. Medicines were stored and disposed of securely. Administration records were up to date.” from the report
PRN medicine instructions
needs fixingSome instructions for medicines given when needed did not state the maximum dose in 24 hours. One medicine was being given regularly. The manager reviewed the protocols immediately.
“PRN (as required) protocols did not always contain sufficient information about the maximum dose allowed in 24 hours and one medicine was being given on a regular basis.” from the report
Infection control checks
needs fixingSome open food was not labelled, some hand sanitisers were empty and the cleaner had not started work when inspectors visited. The manager took immediate action.
“We found some hand sanitisers were empty and the cleaner had not started work.” from the report
Cellar door left open
minorThe cellar door was accidentally left open. The director added locks to doors including the cellar and cleaning cupboards after the inspection.
“We found the door to the cellar had been left open accidentally.” from the report
- 01What changes were made after the review of the PRN medicine protocols, and how are staff checked to make sure maximum doses are clear?
- 02How do you now make sure hand sanitisers, food labelling and cleaning arrangements are checked every day?
- 03What additional checks are in place to prevent doors such as the cellar door being left open?
- 04How will you show that the improvements made after the Inadequate rating are being maintained?
- 05What can you tell us about the serious incident mentioned in the report, and how have you responded to it?
This was an unannounced focused inspection of Safe and Well-led, including infection control under Safe; the other key question ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 10 March 2021 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 Winterfell Care Home
4 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- October 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2021Goodup from InadequateSafe: GoodWell-led: Good
- February 2021Inadequatedown from GoodSafe: InadequateWell-led: Inadequate
- January 2020GoodSafe: GoodWell-led: Good
- October 2018
Registered with the Care Quality Commission on 3 October 2018.
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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