Winfrith House

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant people’s needs were not always met.

Care planning did not consistently support personalised and responsive care. Records did not always reflect people’s aspirations, communication needs, or support to access the community. Person-centred care planning was inconsistent, and information was not always clear, detailed, or up to date to guide staff practice.

This increased reliance on individual staff knowledge and reduced assurance people’s needs would be met consistently over time, particularly during staff absences or changes in staffing. Although we observed staff responded appropriately to people’s immediate needs and de-escalated behaviours using positive communication strategies and offered choice. Weaknesses in documentation, review, and oversight limited the provider’s ability to demonstrate care was planned, reviewed, and adapted in response to people’s changing needs and preferences.

The provider was in breach of the legal regulation person-centred care.

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 consistently ensure people were at the centre of their care and treatment or actively involved in decisions about changes to their support. Some care plans were incomplete, reactive, or lacked guidance on routines and preferences.

Care planning did not consistently support personalised care. For example, 1 person’s personal care plan had not been reviewed in line with provider timescales and contained minimal detail about daily routines or individual preferences. Positive Behaviour Support plans largely focused on reacting to challenging behaviours rather than promoting proactive strategies to reduce incidents or enhance positive outcomes. For example, housing care plans identified potential risks, such as noise disturbances, but lacked guidance on triggers or preventative measures.

Staff practice demonstrated responsive, person-focused care. Where more detailed PBS and emotional support plans were in place, staff encouraged independence and followed proactive guidance to reduce incidents.

Care, treatment, and information were not consistently coordinated across services to provide fully integrated, continuous support. Staff delivered care effectively in the moment, but gaps in documentation and care planning limited formal continuity with healthcare and social care partners.

Communication and information sharing with partners were inconsistent. Some liaison occurred with external services, such as the intensive support team and social workers, but evidence of structured or consistent communication to support proactive planning for 1 person was limited. Reliance on staff knowledge rather than updated documentation increased the risk of inconsistencies and delayed responses to changing needs.

Staff knowledge mitigated some risks, but systems were not embedded. Staff engagement helped maintain practical continuity, but care could vary depending on which staff were on duty. The provider acknowledged the need to improve care records, planning, and mechanisms for integrating information from health and social care services to ensure consistently safe, coordinated, and person-centred support.

Information was not consistently provided in a way that met people’s communication needs or supported understanding of care and support.

Written materials did not consistently reflect people’s individual communication needs. For example, the service user guide was text-based and unlikely to be accessible for people using the service. It did not incorporate communication strategies such as pictorial aids, Makaton, or visual tools outlined in care plans.

Staff used personalised communication strategies in practice. Positive practice was observed where staff used ‘Now and Next’ boards, flashcards, and Makaton to support routines and transitions. One care plan specifically guided staff on Makaton use to enhance communication. A relative told us, “There is good communication within the home and with me,” reflecting effective engagement in day-to-day care.

The provider acknowledged written materials should better align with individual communication needs and confirmed plans to review and adapt information.

People’s ability to provide feedback, share ideas, or raise concerns was limited. Care plans did not consistently reflect individual choices, and there was no systematic approach to recording, analysing, or responding to feedback and complaints.

Feedback and complaints processes were underdeveloped. Evidence of input from people, relatives, or partner agencies was limited. Complaints were not consistently logged, and outcomes were not documented. Whilst staff involved people in day-to-day decisions, this engagement was not consistently recorded or used to inform improvements in care.

Positive examples demonstrated individual engagement. A relative told us, “I do know how to complain, but I have not needed to. We have an open and honest relationship, and I am confident the manager would raise issues promptly.” This reflected good individual engagement, but systematic collection and use of feedback were limited.

The provider acknowledged the need to implement formal processes for gathering, analysing, and acting on feedback. Establishing these systems would strengthen co-production, ensure transparency, and help people influence the development and improvement of care and support.

The service did not consistently ensure equitable access to care and support tailored to individual needs. Staff delivered day-to-day care effectively, but gaps in documentation and emergency protocols limited assurance of consistent access, particularly out-of-hours.

Emergency and out-of-hours arrangements were not clearly defined. The registered manager held dual registration for 2 services and was on call 24/7, but staff did not have clear procedures to manage emergencies in their absence.

Care planning did not consistently support equitable access. Plans inconsistently detailed strategies for attending healthcare or community appointments.

The provider acknowledged the need to improve emergency protocols, out-of-hours arrangements, and care plan guidance. Embedding these improvements would help ensure consistent, reliable, and equitable access to services for everyone using the service.

Staff and leaders did not consistently use information about people at risk of inequalities to shape care. As a result, experiences and outcomes were not always tailored to individual needs or designed to reduce inequalities.

Staff relied on practical knowledge rather than structured guidance, and leaders had limited oversight to ensure support approaches reduced inequalities. The provider acknowledged the need to strengthen systems to identify and respond to potential inequalities.

People were not consistently supported to plan for significant life changes or make informed decisions about their future, including end-of-life care.

Structured planning and documentation were limited. There was little evidence of proactive discussions or systematic planning. For example, no documentation was available regarding future wishes or end-of-life preferences for 1 individual. Attempts to engage a family member for another person were limited, and no formal process for future planning was evident.

Some positive practice was observed but not embedded. Preliminary conversations with family members took place to understand preferences, but these were not consistently recorded or integrated into care plans.

The provider acknowledged that future planning required development and confirmed plans to implement structured processes to assess, record, and review people’s preferences, including potential end-of-life decisions.