Winfrith House

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

Care and support were not consistently effective or delivered in line with legal requirements. The provider did not consistently follow the Mental Capacity Act 2005. Mental capacity assessments and best interest decisions lacked decision-specific detail and did not consistently evidence people’s involvement or appropriate consultation with family members or relevant professionals. These were repeat concerns from previous inspections and had not been fully addressed.

Staff were able to recognise changes in people’s health and sought advice from external healthcare professionals when needed. However, gaps in care planning, record keeping, and management oversight limited assurance that care was consistently effective, lawful, and based on best available evidence.

The provider was in breach of the legal regulation consent.

This service scored 50 (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 did not always ensure people’s care and treatment were effective because they did not consistently check and discuss health, care, wellbeing, and communication needs with them. For example, 1 person’s care plan had not been updated in over a year, their social care, personal care, goals, and sensory sections were incomplete.

Assessment processes did not provide a comprehensive or up-to-date understanding of people’s needs. Pre-admission assessments were not available for 1 person, which meant there was insufficient evidence the provider completed an assessment before or after admission. For another person, their life skills goals, including laundry and domestic tasks, had not been reviewed for several months. This limited evidence goals remained relevant or progress was being monitored.

People’s’ care planning did not consistently reflect their current needs or preferences. Records did not always capture people’s routines or communication requirements, in sufficient detail. There was limited evidence people, or those who knew them well, were involved in reviewing or updating assessments. This reduced assurance care could be adapted in response to people’s changing needs.

Although staff delivered care that reflected peoples’ known needs, this relied on staff’s familiarity rather than effective systems. The provider acknowledged assessments required review and improvement. Without regular updates, structured review processes, and meaningful involvement, the service could not demonstrate care would remain effective, personalised, or responsive over time.

Care and treatment were not consistently planned or delivered in line with best practice.

Care planning did not consistently support preventative or outcome-focused approaches. Care plans primarily focused on responding to incidents rather than preventing them or promoting positive outcomes. For example, Positive Behaviour Support (PBS) plans included basic reactive strategies but did not consistently identify behavioural function, known triggers, incentives, or rewards. This limited staff’s ability to use proactive strategies to reduce the likelihood of incidents.

Nutritional planning was not consistently accurate or aligned. We found instances where nutritional guidance was incomplete or contradictory. For example, 1 care plan stated a person was not at risk of choking but prompted staff to remind the person not to put so much food in his mouth at once. These inconsistencies reduced assurance staff had clear and reliable guidance to support safe and appropriate care.

Staff had completed accredited positive behaviour management training and followed Speech and Language Therapy guidance, which provided a foundation for safer practice. However, care documentation did not consistently translate this guidance into clear, proactive, and person-centred plans.

The provider acknowledged PBS and nutritional plans required review. Plans were in place to update care documentation to be more outcome-focused, preventative, and clear. However, at the time of inspection, these plans had not yet resulted in consistently embedded, evidence-based care planning.

Staff, teams, and external services did not always work together effectively because the provider did not have reliable systems to support and record coordinated care.

Healthcare professionals told us they worked well with the service and that communication with staff was generally good. However, the provider did not have effective systems to evidence, record, or consistently support multidisciplinary working and information sharing.

The provider was unable to provide consistent evidence of multidisciplinary team (MDT) meetings or structured communication with external professionals. Handover records and communication books were not used consistently and often lacked sufficient detail to reflect people’s changing needs or actions agreed with professionals.

Care records were not always up to date, which reduced their reliability for staff and for external healthcare professionals involved in people’s care.

There was limited evidence to show that people were involved in reviewing their care when professionals were consulted or when care changed. As a result, the provider could not consistently demonstrate that care was coordinated, reviewed, and responsive to people’s changing needs, despite positive feedback from external professionals.

The provider did not consistently support people to manage their health and wellbeing, reducing opportunities to maximise independence, choice, and control.

Health and wellbeing planning did not provide effective support for proactive care. Plans contained limited guidance on how staff should support people to access healthcare or manage appointments. For example, plans lacked detail on strategies to reduce distress or barriers, such as the use of social stories, desensitisation approaches, or communication aids. One person’s health and wellbeing plan had not been updated since May 2023, and another plan was incomplete.

These gaps reduced assurance that health needs would be met consistently and limited the provider’s ability to deliver proactive care to prevent deterioration or reduce future support needs.

The provider acknowledged that health and wellbeing plans required review. Without regularly updated plans that included preventative strategies and clear guidance on individual preferences, the service could not demonstrate that people were consistently supported to maintain their health, access services effectively, and benefit from proactive support.

The provider did not consistently monitor people’s care and treatment to improve outcomes or ensure they met clinical expectations and individual preferences.

Monitoring arrangements did not reliably support continuous improvement. Where care plans were in place and followed, inspectors observed positive practice. Staff supported skill development and maintained routines. However, without structured review processes and outcome tracking, progress was not consistently evaluated. This limited the provider’s ability to improve care over time or demonstrate that support remained personalised and effective.

The provider acknowledged gaps in monitoring and told inspectors they planned to introduce regular, outcome-focused reviews. However, at the time of inspection, these arrangements were not embedded.

The provider did not always inform people of their rights or consistently apply consent processes in line with the Mental Capacity Act (MCA) 2005.

Previous regulatory breaches relating to consent had not been fully addressed. Documentation of mental capacity assessments and best interest decisions remained inconsistent. In some cases, best interest decisions were overly general and did not clearly specify the exact decision being made. Records did not consistently evidence the involvement of people, family members, or relevant professionals, reducing assurance that decisions were made lawfully and in people’s best interests.

Consent processes were not reliably decision specific. Staff made attempts to involve people by gauging understanding and preferences, and standard templates were used in some instances. However, these approaches were not applied consistently or tailored to individual decisions. This increased the risk decisions about care and treatment could be made without appropriate legal safeguards.

The provider acknowledged further improvement was required and told inspectors they planned to review and strengthen MCA processes. At the time of inspection, systems were not embedded. Clear, decision-specific documentation and consistent involvement of people and relevant parties was needed to ensure consent was applied in practice and legal requirements were met.