Winslow House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in continued breach of the legal regulation of safe care and treatment.

This service scored 53 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to identify and embeded good practice. The provider promoted an open culture within the home. The provider kept records of accidents and incidents. Accidents and Incidents were reviewed monthly to determine any themes and actions needed. The provider had started to implement a new system to improve the effectiveness of accident reporting and analysis.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People were accepted into the service safely. The service had good relationships with health and social care professionals. A member of the local GP practice visited weekly. Information showed staff recorded concerns to be raised with health professionals. Outcomes were documented and acted upon.

Issues with equipment people used had been identified by the service. They were actively seeking advice and input from the local nursing team to resolve this.

People and their relatives we spoke with told us they felt safe.

Systems were in place to manage and act on safeguarding concerns. Staff knew how to identify and report safeguarding concerns. People and their relatives were able to raise concerns with the management team. One person told us, “The staff are wonderful here. Looked at 3 places and this was the preferred option. We couldn’t have nicer staff.”

Some staff and people we spoke with did not think there was enough staff to safely support people. A staff member said, “Staffing is main issue, only 2 on night shift. Inherited situation but don’t feel breaks are adequate.” We discussed this with provider during our assessment who told us they were purchasing a dependency tool to support them with ensuring there were enough staff on duty at the right times to keep people safe.

The service completed Mental Capacity Assessments (MCA) for people who could not make a decision about their care. However, there were some gaps in decision specific mental capacity assessments and best interest decisions, or the records had not been fully completed. The provider had an action plan they were working on to ensure records were brought up to date and completed with the relevant information. This had not had time to embed across the service at the time of our assessment.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service had a range of risk assessments for people, there was an ongoing plan for reviewing and updating assessments. However, this had only recently been implemented and was not fully embedded at the time of the assessment. The quality and consistency of risk assessments varied and there were gaps in some people’s care records. A diabetes risk assessment for one person demonstrated good practice for staff to follow in terms of signs to look out for if the person was becoming unwell. However, some people’s catheter care risk assessments required more detail to ensure people were safely supported. Whilst medicine’s people were prescribed had general risk assessments around areas such as self-administration and support needs, other specific risk assessments for example, for paraffin-containing emollients were missing. This is important because emollients are easily transferable between skin and clothing and bedding, paraffin based emollient creams can pose a fire risk to a person using them.

Staff we spoke with understood people’s needs. One staff member told us, “Care records make it easy to see (people’s needs) if needed. Food controlled because of choking risk we are made aware and people have specialist diets. Always explained to staff including agency of anyone at risk.”

The provider did not detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

There was a process for reporting faulty or broken equipment and any risks in the environment. However, on day one of the assessment we identified issues with a leak in the laundry room and this had not been identified as a potential safety risk. This presented a hazard to staff and an electrical safety issue. Some of the furniture people used was in a poor condition and had not been identified as a potential infection issue. For example, lap table surfaces were damaged exposing sections of the table to bacteria and dirt. This is important because people used these tables to eat and drink from.

During the assessment we found the lift was out of order. There were not any signs to notify people. Some people with mobility needs could not access downstairs. Services are required to notify CQC of events which stop the service operating safely. The provider took action during the assessment to address this. A notification was submitted to CQC and on the second day of the assessment signs were displayed to show the lift was out of order. A risk assessment regarding the impact and management of the lift being out of use was completed.

Checks to gas, water, electrical safety and portable appliances were carried out. The service conducted fire drills.

The provider did not always make sure there were enough qualified, skilled and experienced staff deployed at the right times. They did not always work together well to provide safe care that met people’s individual needs

At the time of the assessment, the provider did not have an effective tool for measuring safe staffing levels for the service. Rotas we reviewed showed inconsistencies in numbers of staff at certain times of day.

Feedback from some people and their relatives we spoke with told us there were not enough staff especially in the early evening and overnight. One person told us, “There are not enough staff here, especially nights. If you need the toilet it takes a long time to get to you, one thing I don’t like.” A relative said, “would benefit from more staff. Uncertainty and long waits for care contribute to things not being passed on.” Staff told us, “Sometimes hard to find enough staff to help, whilst supporting residents’ personal choice, particularly at meal times.”

We found gaps in training for staff, whilst the provider had started a programme of training for staff it had not been fully implemented at the time of our assessment. We identified a number of staff had not completed core training such as safeguarding, mental capacity, deprivation of liberty safeguards and infection prevention and control. This is important because people could be put at potential risk of harm if staff are not trained to care for people safely. The provider had recruitment processes to ensure staff employed were suitable for the role. This included reference checks, Disclosure and Barring Service (DBS) checks and right to work checks for overseas staff.

The provider had started supervisions for staff and there was a plan in place for the rest of the staff to have supervision and appraisals. Management carried out spot checks on staff care practices.

The provider did not assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We identified infection control concerns with the laundry room and some of the furniture people used.

The service’s infection prevention and control (IPC) policies and procedures reflected current best practice guidelines. However during the assessment staff were observed in the laundry room not following the service’s IPC policy. Several staff members had not undertaken recent IPC training at the time of the assessment. This is important to help staff understand the risk of poor IPC and the potential impact on the people who live at the service. We found the service did not have a safe system for separating clean and soiled washing. This is important to prevent cross contamination. Staff followed a daily cleaning schedule, however, this was not being updated to reflect the cleaning carried out.

We raised our findings with the provider, who started to address our concerns during the assessment.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines were well managed. The training process around the management and administration of medicines was robust, involving online and face-to-face training and supervised competencies. There was also a medicine policy that covered all aspects of medicines handling in the service. Medicines were stored securely in locked cupboards and fridges in people’s rooms. Temperature checks for fridges were completed. Medicine audits and error investigations were completed. Medicines were administered as prescribed, including those medicines that were time specific. Protocols for as required (PRN) medicines were present. One person that had a transdermal patch applied weekly did not have regularly check that it was still in place. One medicine which was prescribed and had a PRN protocol did not appear on the Medication Administration Record chart. This was addressed with the provider at the time of the assessments and took immediate action to remedy our concerns.

In all cases allergy statuses were recorded. Staff had good knowledge of the medicines they were administering, particularly around people’s preferences. Medicines that required additional management in line with legal requirements were stored appropriate.

People told us their medicine was managed well. One person said, “They bring my pills along and stay with you whilst they make sure you take them. I do know what they are for.”