Winchley Home

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• 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 Good. At this assessment the rating has changed to 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 in relation to governance at the service.
 

This service scored 29 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities. Shortfalls identified within this inspection in relation to consent and person-centred care did not demonstrate a culture which had a joined-up approach, and care provision failed to be informed by the relevant legal framework and best practice. Due to a lack of mental capacity assessments in line with Mental Capacity Act 2005, the service could not be assured people’s human rights were being upheld.
Audits had not always been completed, and systems were not in place to effectively monitor the quality of care provided or drive improvement. The provider had not identified significant shortfalls such as missing or out of date risk assessments for environmental hazards and gaps in governance processes.
 

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively. The long-standing registered manager had left the service in December 2025, and an acting manager was in place. The provider had not identified the learning needs of the acting manager, for example the acting manager informed us they unaware of information that was required to be notified to CQC, what AIS was or that the service should receive Patient Safety Alerts, recalls and rapid response reports issued from the Medicines and Healthcare products Regulatory Agency (MHRA) and through the Central Alerting System (CAS). Although they were eager to expand their knowledge and skills, the provider had not given support and guidance to ensure the effective management and oversight of the service.
The provider was not aware of all relevant guidance to support safe, high-quality care and treatment.
 

People did not always feel they could speak up and that their voice would be heard.
Most staff felt able to raise safeguarding concerns and that they would be listened to if they did, however, some staff felt their concerns would not be listened to or addressed. Staff meetings were infrequent and staff meeting minutes did not include that staff had been asked about safety concerns or encouraged to speak up. Supervision and appraisal of staff was also infrequent, limiting the forums for staff to discuss any concerns they had.
The provider had a whistleblowing policy in place.
 

The provider did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff had not received training on equality, diversity and inclusion. Most staff felt they were treated equally; however, some told us they felt they were treated differently or that they felt other staff were treated more favourably. A staff member told us, “Only certain staff are listened to.” When asked if any staff had any reasonable adjustments in place, the acting manager said they were unaware of what this meant.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The provider did not have a clear oversight of quality and risk in the service which contributed to people being at risk of avoidable harm and of continuing to receive poor quality care. The provider’s systems to monitor and improve the safety and quality of care provision were not effective. Monitoring and auditing processes were either not in place, were incomplete or unsuccessful in identifying issues within the service. We found there had been limited identification, assessment or mitigation of individual risks. Staff did not always have guidance in how to manage people’s risks when providing their care.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.
The service worked with some external professionals, such as GPs and community district nurses, however we found they did not utilise other services to support people’s specific health needs such as the community diabetes team.
We found that most incidents which had been raised by the service to the local authority had not been notified to CQC as required.
 

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.
There was little evidence of a learning culture. Incidents were not investigated or recorded systematically, and lessons learned were not shared. Systems were not in place to effectively monitor the quality of care provided or drive improvement.
There was no clear support system in place to induct and support the acting manager into the manager role.
We raised the concerns we found during our inspection with the provider. We sought immediate assurances from the provider to take action to significantly improve the service people were provided with. The provider was responsive and developed an action plan to address the improvements required.
The provider had an improvement plan in place, the provider had recently refurbished half of the home.