- Care home
Archived: Winsford Grange Care Home
Assessment report published 26 November 2025
Contents
Ratings
Our view of the service
Date of assessment - site visits were completed on 13, 14 and 18 August 2025 and a review of information was undertaken remotely. Winsford Grange is a care home providing personal and nursing care for up to 60 people. At the time of our assessment there were 28 people residing there.
Winsford Grange is a 'care home'. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Winsford Grange is a care home with nursing care. CQC regulates both the premises, and the care provided, and both were looked at during this assessment.
At our previous assessment we identified the provider was in breach of regulation 9, 10, 11, 12, 13, 14, 15, 17 and 18. There have been some improvement however, we found the provider continued to be in breach of regulation 11 need for consent, regulation 12 safe care and treatment, regulation 13 safeguarding service users from abuse and improper treatment, regulation 17 good governance and regulation 18 staffing, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. There is enforcement action currently active, therefore no further enforcement action will be required.
During our assessment, we found that care plans and risk assessments were not consistently accurate or detailed enough to ensure people’s safety.
Accidents and incidents were not monitored or investigated properly, with limited evidence of follow-up or analysis to identify root causes or implement preventative actions. Wound management was poor, with inconsistent monitoring, and inadequate documentation, raising concerns about the quality of care provided. There were duplicate forms in use for recording accidents, incidents, and wounds, resulting in confusion and a lack of consistency in reporting and oversight. This fragmented approach made it difficult to track patterns. Furthermore, there was little indication that lessons were learned following incidents, with missed opportunities to improve practice and prevent recurrence. Medicines were not always managed safely with missed doses and lack of person-centred detail to ensure people received the correct dose when required. Not all staff had received adequate training to safely meet the needs of people living at Winsford Grange, including those with specific health conditions such as epilepsy or diabetes, which further compromised the safety and quality of care.
Mental capacity assessments and best interest decisions were not consistently completed. As a result, some people may have received care or interventions without the necessary safeguards in place or being followed or without due consideration of their rights and personal preferences. In some cases, we observed people being subjected to restraint without the appropriate legal authority.
We identified there was a high number of people residing in Winsford Grange that had sustained unexplained injuries including, skin tears, bruises and moisture lesions.
Due to incomplete investigations into accidents and incidents, and a lack of effective oversight, some cases that required safeguarding actions were not appropriately addressed. As a result, potential Section 42 enquiries could not be initiated in a timely manner, and crucial evidence may not have been available.
CQC made 3 safeguarding referrals from incidents found during the assessment that had not been referred by the provider.
We also identified CQC had not been informed of safeguarding referrals, which raised concerns regarding regulatory oversight. Timely notification to CQC is a legal requirement and crucial to enable effective external monitoring, ensure compliance with safeguarding standards, and support accountability within care services.
People's experience of this service
People using the service consistently described staff as caring and kind and expressed satisfaction with the support they received. However, one relative noted that while some staff were “alright,” others were better, highlighting inconsistency in staff performance.
There was no documented evidence of people using the service being actively involved in their care planning, although relatives confirmed their involvement in review meetings.
Staff told us there were sufficient staffing levels; however, we identified a lack of suitably qualified staff to meet the needs of the people residing at the service.
People told us they could access a GP when needed and had choice over their clothing and evening routines. However, we observed instances where staff were restricting people without appropriate legal authority under the Mental Capacity Act.
Staff also told us that financial constraints imposed by the provider limited what could be offered to people.
We saw positive interactions between staff and people who lived at the service, and staff appeared to know people well.
Whilst people were generally happy with the support they received, their experience is not reflected in the findings from this assessment. We found the service did not meet the minimum standards that people should be able to expect when in receipt of services in a care home. The quality and safety of the care provided did not reflect the care, treatment and safety of peoples assessed needs.