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St Winifred's Dementia Residential Care Home Requires improvement


Inspection carried out on 2 December 2019

During a routine inspection

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 carried out on 21 November 2018

During a routine inspection

The inspection took place on 21 and 22 November 2018 and was unannounced.

St Winifred’s is a ‘care home’ for up to 65 people supporting them with nursing needs and dementia. People in care homes receive accommodation and personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

There were 48 people living at the service at the time of our inspection. The service was set in a large house that had been extended which was based in a residential area. The accommodation was spread over two floors each floor having two lounges.

There was a registered manager at the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last inspection the service had an overall rating of ‘Good’. This inspection report is written in a shorter format because our overall rating of the service has not changed.

At this inspection, we found the service remained ‘Good’.

People continued to be protected from abuse. Staff understood how to identify and report concerns. Medicines were managed safely, and people received their medicines when they needed them. Risks were assessed and there were actions in place to minimise risk and keep people safe.

There continued to be sufficient numbers of staff who had the skills and knowledge they needed to support people living at the service. Staff were appropriately supervised and supported. New staff had been recruited safely and pre-employment checks were completed.

Peoples’ care met their needs. Care plans continued to accurately reflect people’s needs and included information on their religious and cultural needs. We observed that staff followed the guidance in people’s care plans. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice. Staff were aware of people’s decisions and these were respected.

Staff continued to support people to maintain their health and wellbeing. People had access to healthcare services. People were supported to eat and drink safely with a variety of choice.

People were treated with respect, kindness and compassion. Their privacy was respected, and they were supported to lead meaningful and dignified lives. People were supported to maintain their independence. There were systems in place to seek feedback from people to improve the service. People were encouraged to express their views and were listened to.

The building had been adapted to meet people’s individual needs. People had been involved in the decoration for their room. Staff were aware of infection control and the appropriate actions had been taken to protect people.

The service was well-led. People knew the registered manager well. Staff told us that they were happy at the service and were proud to work there. The service was regularly checked to identify where improvements were needed, and actions were taken.

Incidents were recorded, investigated and acted upon. Lessons learnt were shared and trends were analysed. The service worked in partnership with other agencies. The registered manager was well informed about best practice and shared this learning thought the service.

Further information is in the detailed findings below.

Inspection carried out on 7 June 2016

During a routine inspection

We carried out this inspection on the 7 and 9 June 2016, it was unannounced.

St Winifred’s Dementia Residential Care Home is a service that provides accommodation and personal care for up to 59 older people with dementia. The service is wheelchair accessible. All bedrooms have a wash basin and a large proportion of the single bedrooms have en-suite facilities. The home has five lounge/dining areas. Service users also have the benefit of well-maintained and accessible gardens. At the time of the inspection, 39 people were living at the service.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The registered manager understood when an application should be made. They were aware of the Supreme Court Judgement which widened and clarified the definition of a deprivation of liberty. The service was meeting the requirements of the Deprivation of Liberty Safeguards.

People were protected against the risk of abuse. Relatives told us they felt people were safe. Staff had been trained and recognised the signs of abuse or neglect and what to look out for. The registered manager, deputy manager and staff understood their role and responsibilities to report any concerns and were confident in doing so.

Staff were recruited using procedures designed to protect people who need safeguarding. The registered manager had ensured that they employed enough staff to meet people’s assessed needs. Staff were available throughout the day, and responded quickly to people’s requests for help. Staff had the knowledge and skills to meet people’s needs, and attended regular training courses. Staff were supported by the registered manager and deputy manager and felt able to raise any concerns they had or to make suggestions to improve the service for people.

Staff were trained to meet people’s needs. They met with management and discussed their work performance at one to one meetings and during annual appraisal, so they were supported to carry out their roles.

People and their relatives were involved in planning their own care, and staff supported them in making arrangements to meet their health needs. Staff contacted other health and social care professionals for support and advice.

Medicines were managed, stored, disposed of and administered safely. People received their medicines when they needed them and as prescribed.

There were risk assessments in place for the environment, and for each person who received care. Assessments identified people’s specific needs, and showed how risks could be minimised. There were systems in place to review accidents and incidents and make any relevant improvements as a result.

We observed staff that were friendly and compassionate. Staff delivered care and support calmly and confidently. People were encouraged to get involved in how their care was planned and delivered. Staff upheld people’s right to choose who was involved in their care and people’s right to do things for themselves was respected. People demonstrated that they were happy at the service by smiling and chatting with staff who were supporting them. Staff interacted well with people, and supported them when they needed it.

People were supported to eat and drink enough to maintain their health and wellbeing. People were provided with a diet that met their needs and wishes. Staff ensured people had access to food, snacks and drinks during the day and at night. Staff respected people and we saw several instances of a kindly touch or a joke and conversation as drinks or the lunch was served.


Inspection carried out on 5 March 2014

During an inspection looking at part of the service

Our inspection of 7 January 2014 found that improvements were needed to ensure that people were protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines.

During this inspection we found that improvements had been made and the provider was compliant.

We visited the office and spoke with the Registered Manager and four members of staff. We also spoke with three people using the service.

We found that new systems had been implemented to make sure people were receiving their medication safely. People told us that they received their medication on time each day. One person was able to tell us about the medicines they took and how they were supported to take them safely.

People said: �The staff are polite and friendly, I would recommend the home�. �The staff are very careful with my medicines they help me take them. I have monthly blood tests to make sure I am OK�. �I am comfortable here; my medicines are always available when I need them�.

Staff told us that the management of the medication had improved and the new systems in place made sure the medicines were being given to people as safely as possible

Inspection carried out on 7 January 2014

During a routine inspection

We used a number of different methods to help us understand the experiences of people using the service. Many of the people using the service were not always able to tell us about their experiences. We observed how people interacted with staff and the management of the service. We saw the atmosphere in the service was calm and relaxed. Some people were able to tell us they liked living at the service and staff were kind and respectful.

We observed that staff spoke with people in a positive manner and supported them in their daily lives, such as moving around the premises, chatting, watching television, playing games or eating and drinking.

The staff told us that consent for care and support was obtained from people using the service or their representatives during discussions about the care and support the person needed.

People's needs were assessed before and when they first started to use the service. We found that people�s health care needs were monitored and community health professionals were involved to provide advice and support when needed.

People were not protected against all the risks associated with medicines because appropriate arrangements were not always in place in relation to obtaining medicine.

Staff recruitment records showed that new staff had been thoroughly checked to make sure they were suitable to work with vulnerable people.

People and relatives told us they did not have any complaints but would not hesitate to speak to the manger or staff if they had any concerns.

Inspection carried out on 6 November 2012

During a routine inspection

We spent some time with the people and observed interactions between the people and the staff during a game of bingo. We saw staff reassuring people, listening to what they were asking or saying and acting on it. Staff kept the people engaged throughout the activity and sweets were offered to everyone when they had a break.

We saw that people were responsive in the company of staff and smiled as they walked through the unit. We observed people drinking tea and coffee and chatting with staff and each other. People were not rushed and were supported to do things in their own time. A relative told us "They don�t hurry my relative".

People told us that staff were polite and cheerful and they responded quickly if they needed any help. People said they felt safe using the service

They told us that the home was very clean and the food was good. People said: �This is an excellent home. I love it here, the food is good, it's very clean and the staff are very polite and cheerful. I have been here a long time�.

Inspection carried out on 28 February 2011

During a routine inspection

People told us their relatives had discussed their care and support with staff although this was not always recorded in their care records. People were being supported to make decisions about their day to day lives. They said the food was good and they had a choice of menu at all meal times. People received their medicines safely and on time. There was a maintenance plan in place and the home was warm and comfortable. People who use the service, relatives and staff told us the home was always clean and tidy. People and relatives told us the staff were all very kind and caring and they were treated with respect. Staff were recruited safely and a training programme was in place to make sure they are supported to do their jobs well. The manager told us that she was reviewing staffing levels to make sure people's needs were fully met. There were checks in place to make sure the service ran smoothly and people were satisfied with their care. People and relatives felt confident to raise concerns but did not have any. Records were stored safely and securely.

Reports under our old system of regulation (including those from before CQC was created)