Updated 22 October 2025
Date of assessment: 3 to 5 December 2025.
Winfrith House is a residential care home. This specialist service is used by younger adults with a learning disability or autism. This service supports up to 2 people.
A responsive assessment was triggered following a safeguarding concern regarding a resident’s safety and wellbeing, after reports of significant distress and potential lack of appropriate supervision.
We have assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.
We identified 6 breaches of legal regulations relating to person-centred care, consent, safe care and treatment, safeguarding people from abuse, staffing and governance. These breaches demonstrated significant and widespread shortfalls in leadership, oversight, and quality assurance arrangements. As a result, the provider could not demonstrate that people consistently received safe, effective, and person-centred care.
The provider was previously in breach of the legal regulations in relation to consent to care and governance. Although some actions had been taken, these were not sufficient to achieve compliance. The provider remained in breach, which demonstrated a failure to learn and embed improvements from previous regulatory action.
People’s care records did not always contain clear, accurate, or up-to-date information to guide staff. For example, key information was incomplete or inconsistent across records. This increased reliance on individual staff knowledge and reduced assurance people’s needs would be met consistently, particularly during staff changes.
The provider did not always follow the Mental Capacity Act 2005. Mental capacity assessments and best interest decisions were vague, lacked decision-specific detail and did not consistently evidence people’s involvement or appropriate consultation with others, placing people at risk of decisions being made without legal safeguards.
Risk management systems did not provide effective oversight. The provider did not consistently identify or mitigate individual, environmental, or infection prevention and control risks. Medicines management processes were unsafe. We found insecure storage, incomplete medicines records, inconsistent monitoring, and a lack of effective audit processes or staff competency assessments. These issues increased the risk of missed doses, administration errors, or medicines being given without appropriate oversight.
Safeguarding and incident management processes lacked effective oversight. Managers did not consistently analyse incidents or safeguarding concerns to identify themes or learning. This limited the provider’s ability to reduce recurrence and protect people from ongoing risk.
Staffing arrangements did not always ensure people received safe care. Overnight staffing levels did not reflect people’s assessed needs, which increased the risk support might not be provided safely during emergencies or periods of heightened distress. Recruitment records were incomplete, training and supervision arrangements were inconsistent, and agency staff were deployed without sufficient assurance of competence.
Governance systems were not effective in monitoring care quality, risks, or compliance. Audits were absent or incomplete, and previous regulatory breaches had not been addressed. The registered manager’s dual registration, combined with limited oversight from the nominated individual, further reduced leadership capacity.
Although staff were observed to be kind, respectful, and responsive in their interactions, these positive practices did not mitigate the risks arising from ineffective leadership and governance arrangements.
In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.
We have asked the provider for an action plan in response to the concerns identified at this assessment relating to person-centred care, consent to care and treatment, safeguarding, and staffing.