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St Winifred's Dementia Residential Care Home Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 8 January 2020

About the service

St Winifred’s Dementia Residential Care Home is a residential care home providing personal and nursing care to 40 older people at the time of the inspection. The service can support up to 53 people in one large extended building.

People’s experience of using this service and what we found

People told us they felt safe living at the service. However, lack of oversight by the registered manager and provider of the quality of the care and support people received had placed people at risk. Comprehensive checks and audits had not been completed until shortly before the inspection. Once concerns had been raised they were addressed.

Potential risks to people’s health and welfare had not been consistently assessed. There was not always guidance for staff to mitigate the risks. Records of the care people received were not accurate and had not been completed in a timely manner. Medicines were not managed safely. Accidents and incidents had been recorded and action taken but they had not been analysed to identify patterns and trends.

Staff were recruited safely, though improvements were required to the recording of information. There were enough staff to meet people’s needs. However, most of the nursing care was provided by regular agency nursing staff. Staff received training appropriate to their role, but staff had not received regular individual supervisions to discuss their development.

People were supported to eat a balanced diet. People had access to activities they enjoyed and were supported to stay as active as possible. The service had been adapted to meet people’s needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People were given information in a way they could understand and where possible were involved in developing their care plan. People and relatives told us they knew how to complain, and any issues had been dealt with appropriately.

People, staff and relatives had been asked their opinion on the service. The registered manager attended local forums to keep up to date with developments and to continuously improve the service.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was Good (published 29 January 2019).

Why we inspected

The inspection was prompted in part due to concerns received about medicines management, staffing, wound management and care planning. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, responsive and well led sections of this full report.


We have identified breaches in relation to safe care and treatment, person centred care and good governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection areas


Requires improvement

Updated 8 January 2020

The service was not always safe.

Details are in our safe findings below.


Requires improvement

Updated 8 January 2020

The service was not always effective.

Details are in our effective findings below.



Updated 8 January 2020

The service was caring.

Details are in our caring findings below.


Requires improvement

Updated 8 January 2020

The service was not always responsive.

Details are in our responsive findings below.


Requires improvement

Updated 8 January 2020

The service was not always well-led.

Details are in our well-Led findings below.