Archived: Winsford Grange Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question inadequate. At this assessment the rating has remained inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation 17 in relation to governance and oversight within the service.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff had not received adequate training to safely meet people's needs, and despite this being identified as a concern during the previous assessment, the management team had failed to take appropriate action.

Although staff were unfamiliar with the home's specific values and beliefs, they had their own ideas about good practice, such as promoting person-centred care.

There was evidence of one staff meeting however, this was held in response to concerns rather than to encourage staff to share ideas or give feedback on how to improve. Although discussions took place, they mainly focused on reminding staff about their roles and responsibilities, rather than encouraging open conversation or suggestions for change to drive improvements.

Staff told us the culture within the home had improved with one staff member stating, “It feels like the blame culture has gone.”

Whilst staff were happy with the support provided by the registered manager and clinical lead, they raised concerns about the provider. Staff told us that financial restrictions prevented them from purchasing necessary items and offering a varied diet. One staff member said, “There is a limited budget.”

Concerns were also raised about the condition of people’s bedrooms and the lack of funds to refurbish them. One staff member told us, “If I worked for Park Homes, I wouldn’t be here. I work for Winsford Grange.”

Since our last assessment, there have been several changes in the management team. An analysis of information had been undertaken, which included a review of accidents, incidents, and wounds. However, at the time of this assessment, we could not see that any actions had been taken.

People did not always feel they could speak up and that their voice would be heard.

Staff told us they felt confident their concerns would be listened to if raised with the registered manager. One staff member commented, “The registered manager would deal with any concerns I had.” A relative also shared that they had been encouraged to speak up, telling us the registered manager had said, “How can we put things right if you don’t tell us?”

However, not all staff were aware of the whistleblowing policy. One staff member told us they did not know what it was or how to use it.

Where concerns had been raised it was not always clear how they had been investigated or resolved. Some staff had completed staff surveys however, there was no recorded action following these.

Some staff had experienced incidents of abuse from people they were supporting during episodes of challenging behaviour. There was not always clear guidance in place to help mitigate these risks or prevent such incidents from occurring. Additionally, there was no evidence that staff were offered debriefs following accidents or incidents. The incident forms following episodes of behaviours that challenge were not always completed.

Staff had received training in equality and diversity and told us they received regular supervision every three months.

The provider lacked effective systems for governance and accountability, with limited oversight and analysis. Wound care was inconsistently managed, and staff competency in administering topical treatments and using thickening agents was not always assessed. Oversight of incidents and accidents was ineffective, with multiple methods used to record these, leading to inconsistencies in documentation and a lack of follow-up actions. The main tracker intended to serve as the central record for all accidents and incidents lacked key information necessary to mitigate risks or demonstrate learning. Required actions and lessons learned were frequently incomplete, and injuries related to repositioning or unexplained bruising were not adequately investigated through root cause analysis. This has been an ongoing concern, previously brought to the provider’s attention, and reflects a continued pattern of non-compliance.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The provider demonstrated positive engagement with the local authority and partner agencies. However, we identified instances where referrals to the local authority were required but were not completed in a timely manner. We also found incidents where people had experienced weight loss, yet the response was limited to ongoing monitoring without further action. Additionally, there was evidence of unexplained injuries and continued wounds that had not been thoroughly investigated, and some more complex health conditions had not been fully considered. While some people were supported by staff to access the local community, visits to a local café was the only evidence we saw. Some people with more complex health needs were not able to access the community.

The provider did not demonstrate a clear commitment to continuous learning. In cases where incidents occurred, learning was not always completed or followed through. Where lessons were identified, there was no clear evidence that this information was effectively shared with the wider staff team. Although a learning session took place with the management team and providers, there was no indication that the key points discussed were communicated to frontline staff. This suggests that management did not take sufficient proactive steps to ensure care staff were informed of key learning outcomes. Evidence from this and previous CQC assessments further highlights ongoing concerns regarding the management’s approach to meeting regulatory requirements.