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 changed to good.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service was in the process of reviewing and updating their Deprivation of Liberty Safeguards information, we saw evidence the provider was following up outstanding DoLS assessments with the supervisory body. 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, and not all records had not been fully completed. This had not been identified in the provider’s action plan, and the provider did not always consider the impact some restrictions may have on people. During the assessment the provider acted on our feedback, updating care records and sought advice from the local authority.

People and their relatives feedback was positive. They told us they felt safe and were able to do the things they wanted. One person told us, “I’ve always got up early. I like to get up at 5.30am and so I requested that they come early, they said yes, we will. They come at 5.30am.” And another person said, “I’ve never been stopped from doing things that I want to do, in fact staff help me in to the garden and to get where I want to go.”

The provider did not always work well with people to understand and manage risks.

At the last assessment in February 2025, we were not always assured risks to people were sufficiently assessed and mitigated, with clear guidance for staff to follow.At this assessment we found some improvements, however there were still gaps in some areas. The provider had not considered the risk of having clinical waste bins that were not secured and were accessible to people living in the home. The provider acted on our concerns during the assessment. We found one person without a risk assessment for the use of a flammable emollient cream, we raised this with the provider at the time.

However, we received positive feedback from people and relatives who told us risks were managed well whilst people still had some independence. One relative told us, “If there are any falls we were informed, not serious but we were still informed. They put mobility support in place, with a stand aid and a walking frame. Staff walk with her.” And one person said, “‘I have been pushed out in a wheelchair regularly, whilst it was quite warm. I always enjoyed my garden, so it’s good to get out into the one here.”

The provider had made improvements since our last assessment however more time was needed to fully embed these. During our visit we observed that a cleaning trolley was left unattended from the start of our visit. This trolley contained items which could pose a harmful risk to people living in the home who may be unaware of the danger and could easily access these. The ‘Control of Substances Hazardous to Health (COSHH)’ states all cleaning chemicals and other substances covered by COSHH are to be locked in a cupboard. Despite multiple staff walking past this trolley, it was not removed or made safe until we raised this with the leadership team. They responded by removing the trolley and ordering trolleys that could be secured when not in use.

We saw that the environment space was compromised by a lot of items cluttering corridors and walkways. For examples several laundry trolleys were positioned along hallways that were not very wide making it hard for some people to navigate. We observed one person struggle to get through a space between a trolley and fire extinguisher with their walking frame. The risk assessment for slips/trips and hazards dated June 2025 stated, ‘staff to keep corridors and passageways clear of obstruction.’ This was not being followed.

We saw that a fire exit had been blocked by laundry trolleys as there was little space to store, all the trolleys. This meant in an emergency people would be at risk of not being able to exit from this escape safely. We discussed this with the provider who started to address our concern during the assessment.

During the assessment management and shift leaders undertook fire warden training, however rotas we viewed did not always reflect a staff member who had been trained to act as a fire warden in the event of a fire. The provider told us more staff were undergoing fire warden training during December, we have asked for an update. We saw that firefighting equipment was being regularly serviced.

The home had completed some redecoration and were working towards further improvements. We saw that people’s lap tables were now clean and in good condition. There was a homely feel to the service which people liked. A relative told us, “It is definitely improving. The decoration is getting better upstairs and in the bedrooms.” And a person told us, “I do have a frame to help me walk about and carers do look out for you here.”

The provider had taken steps to improve staff training overall. The majority of staff had undertaken appropriate training for their role. The service used external trainers for the provision of medicines and infection prevention and control training. However, not all staff had received Mental Capacity Act training, this is important because all staff who have direct contact with people and should have awareness of the Act. The provider told us any gaps in staff training were being addressed within the next 30 days. The provider worked with staff who may need additional support to complete training, ensuring they had a way to complete training that was accessible to them. Staff told us they had received appropriate training. A staff member told us, “Completed safeguarding training. I would report anything that is not right to a resident to a senior or manager. Not raised a concern before.” Another told us, “We do lots of training, every year we do refreshers.”

People and their relatives told us they felt staff were well trained. One person told us, “They have been well trained and are happy to use things like the hoist.” Another person told us, “I do think that the carers do know what they are doing. When they are helping shower me, they know how to take care.”

The provider told us they had increased their staffing levels to support people’s needs. We found the provider had reviewed their staff numbers meaning new shifts had been created to better meet people’s needs. Whilst there was some improved consistency of staff levels we found some gaps on staff rotas that were not covered when staff were off. For example, in housekeeping. This had not impacted on people’s care. The provider told us they had increased staff levels at night and introduced a senior to oversee and delegate to other staff at night. Shifts now overlapped which gave better opportunity for handover between changing shifts. People and their relatives fed back there was a more stable work force since we last assessed. One person told us, “I am involved with 2 or 3 of the carers [regulars] and [activity coordinator] is very good.” Another person said, “Got to know the staff well, usually the same staff but a few agency people when the usual ones are off.”

A relative told us, “Yes. We do see the same staff, some agency in the summer but a lot of regular ones – get to know them.”

Since our last assessment the service had made improvements around the management of infection control in the service. However further improvements were needed in this area to ensure safe procedures were maintained.

Some of the adaptations made to infection control management did not always take into account the needs of people living in the service. For example, clinical waste bins were located outside several rooms lining the corridors. This was not a homely environment for people.

Hand sanitiser dispensers had been placed into everyone’s rooms. This was for staff to have access to, following supporting with personal care. However, this had not been undertaken with people to ensure they were happy for this to be in their bedroom and with consent recorded. There was no risk assessment in place for this should it be a hazard to someone. The provider acted on our feedback during the assessment.

The auditing and monitoring of the cleaning checks in the service needed improvement. There was no current checklist in place to show how often equipment in the home was being cleaned. The leadership team said that staff wipe down equipment after each use but this was not recorded. The leadership team said this had been identified and a checklist had been designed and would be implemented shortly.

The leadership team had sought external advice around infection control management and had completed training sessions and audits with an IPC specialist to improve IPC within the service.

They had received positive feedback about the steps they had taken. A meeting was planned to share this information with the domestic staff roles so they could take ownership of this area.

Staff had received training in infection prevention and control. A staff member said, “Online training for IPC and in person training, had a person come in.”

We saw that improvements had been made to the laundry room. The equipment had been placed above floor level, and the room was clean and organised. One person told us, “It is all very clean; happy with that. The laundry is good, and I am happy with it. It’s quick and it’s frequent. Come back with clothes very quickly – excellent.” And another said, “The room is very clean and the shower room is kept clean as is the en-suite, I stick to a certain laundry day. I save it up and they collect it. I get it back all at once, clean and well pressed.”

Throughout the visit we saw that staff were wearing appropriate personal protective equipment (PPE) to support people with their care and when undertaking other tasks that required this. A staff member told us, “I wear PPE if taking soiled clothes out, and then I change it after putting into washing machine, always wear gloves and aprons, never run out.”

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.