Winfrith House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

Systems to assess, monitor, and manage risk did not keep people safe. The provider did not consistently identify, assess, or mitigate individual risks, environmental hazards, or infection prevention and control risks.

People’s medicines were not managed safely. We found inadequate storage arrangements, inconsistent temperature monitoring, and gaps in medicines records. There lacked an effective audit programme or staff competency framework to support safe medicines administration. These issues increased the risk of errors or medicines being administered without appropriate oversight.

Safeguarding processes lacked effective management oversight. Safeguarding referrals, outcomes, and follow-up actions were not consistently recorded, reviewed, or tracked to completion. Incident reporting was inconsistent and did not support learning or risk reduction. Although individual staff demonstrated awareness of safeguarding procedures and knew how to respond to immediate concerns, these practices were not supported by effective systems, leadership, or governance.

The provider was in breach of the legal regulations safe care and treatment, safeguarding, and staffing.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not promote a positive or open learning culture and did not use incident information effectively to understand risks or improve the quality and safety of care.

Incident management systems did not support learning or improvement. Although staff recorded behavioural incidents records often lacked sufficient detail to enable meaningful analysis. For example, records frequently omitted information about triggers, context, duration, location, and impact.

Staff in some cases, recorded the possible cause or function of people’s behaviours using vague, single-word descriptors, such as “attention.” This limited understanding of why behaviours occurred and reduced the provider’s ability to adapt support strategies. As a result, the risk of repeated incidents and avoidable distress for people increased.

Learning from incidents was not embedded into practice. Staff did not consistently update care plans to reflect incident outcomes or identified learning. This reduced the service’s ability to adapt support arrangements and improve outcomes over time. Although incident records did not indicate significant harm to people, the absence of structured learning reduced assurance that risks were understood or proactively managed.

Management oversight of incident recording and analysis was ineffective. Gaps in recording were not identified or challenged. The registered manager confirmed incidents were not routinely reviewed and that no thematic or periodic analysis took place. This meant the provider did not identify patterns, trends, or opportunities to reduce recurrence, which demonstrated limited oversight and an underdeveloped learning culture.

The provider did not always work effectively with people or healthcare partners to establish and maintain safe systems of care or ensure continuity when people accessed other services.

Information to support safe pathways and transitions was not reliable. Records intended to provide continuity of care were not consistently accurate or up to date. For example, 1 person had a health passport, however, this did not reflect their current prescribed medicines. It omitted nutritional supplements, allergy medication, and treatment for constipation. As a result, the document did not provide a dependable summary of the person’s health needs, which increased the risk of inconsistent or unsafe care when people accessed healthcare services.

Oversight of tools designed to support continuity of care was limited. Although systems such as health passports were in place, staff did not consistently review them or ensure they aligned with care plans. This reduced assurance healthcare professionals would have the information required to make informed decisions when people accessed external services.

The provider acknowledged gaps in oversight and told us they intended to improve review processes. However, at the time of inspection, these arrangements were not embedded or operating effectively, and systems did not provide assurance safe transitions and pathways were consistently maintained.

The provider did not work effectively with people or partners to understand what being safe meant to them or how to achieve this. Safeguarding concerns were not always shared promptly or appropriately.

Safeguarding systems did not protect people from avoidable harm. The provider did not consistently recognise or escalate risks associated with staffing arrangements and periods of escalating behaviour. For example, although overnight staffing was commissioned to meet the assessed needs of 1 person, staff told us they were required to support more than 1 person during periods of escalation. This reduced staff’s capacity and increased the risk people’s needs could not be met safely, including during emergencies such as fire evacuation. Despite meeting safeguarding thresholds, staff had not raised these risks with the local authority.

Managers did not consistently recognise or act on safeguarding concerns. During inspection discussions, the registered manager could not demonstrate whether a suspected choking incident that resulted in a person’s hospital attendance had been reported as a safeguarding concern. The manager told us they relied on another healthcare professional to make this decision. This demonstrated a failure to recognise safeguarding thresholds and take appropriate action.

Oversight of safeguarding concerns was ineffective. Although staff were able to explain how to raise safeguarding concerns the provider could not demonstrate how alerts, actions, or outcomes were recorded, monitored, or reviewed. This limited assurance concerns were followed up and risks managed effectively. Actions taken during the inspection were reactive, and systems to support consistent safeguarding oversight were not embedded.

The provider did not work effectively with people to understand and manage risks in a way that enabled safe, supportive care and meaningful activity. Risk assessments were inconsistent, not regularly reviewed and did not reflect people’s changing needs. There was no evidence people, or those who knew them well, were involved in reviewing or adapting risk plans.

People’s Personal Emergency Evacuation Plans (PEEPs) were not consistently reviewed or updated to reflect changes in behaviour, particularly during night-time hours, or variations in staffing arrangements. For example, 1 person’s PEEP had not been reviewed for over 9 months and did not take account of escalating behaviours or the staffing required to support their safe evacuation.

Fire safety risk management did not consider people’s individual needs. The service’s fire risk assessment was inaccurate and did not reflect the number of people living at the service. It also did not consider people’s communication or sensory needs . People were non-verbal and sensitive to loud noise; however, there was no evidence alternative alert methods, such as visual alarms, had been considered or assessed.

People’s community risk assessments did not provide staff with sufficient guidance. Although records identified anxiety and behaviours that could impact others, they contained limited information about triggers, prevention strategies, or how staff should respond. This reduced assurance risks could be managed consistently when people accessed the community.

During the inspection, the provider took action to commission a new fire risk assessment. However, these actions were reactive and had not yet resulted in updated plans or embedded systems for involving people in managing risk or ensuring risks were consistently identified, reviewed, and mitigated.

The provider did not identify, assess or control environmental risks.

Environmental hazards were not recognised or managed. We identified several risks had not been adequately addressed. For example, a wardrobe was not secured to the wall, which created a tip and crush risk. This was of particular concern given a person’s known behaviours increased the likelihood of furniture being pulled. Window restrictors were not fitted in line with safety guidance, roof access was available, and 1 person had been assessed as being at high risk of trying to leave the service if unsupervised.

Fire safety arrangements did not provide assurance people were protected in an emergency. We found several fire doors did not close properly. Routine fire safety checks did not include clear actions to address identified issues, and the gas safety certificate had expired. These issues increased the risk of injury, unauthorised exit, or harm should an emergency occur.

Environmental infection risks were not adequately controlled. Legionella management arrangements were insufficient. We found inconsistent water temperature monitoring and visible limescale on fixtures. These conditions increased the risk of waterborne infection, including Legionnaires’ disease, and other avoidable infection-related harm.

Environmental risk management relied on being reactive rather than effective systems. During the inspection, the manager took immediate steps to reduce some risks, including securing furniture and replacing window restrictors. The provider also commissioned external fire safety support. Although these actions reduced some immediate hazards, they had not yet resulted in updated risk assessments or embedded systems to ensure environmental risks were consistently identified, monitored, and managed.

The provider did not ensure there were sufficient numbers of suitably skilled, trained and experienced staff. Recruitment, training and supervision systems were not robust and did not provide assurance that care was delivered safely.

The provider’s recruitment and oversight systems did not assure staff competence. Staff files were incomplete and did not consistently evidence interviews, induction, or competency assessments. Appraisals were not carried out in line with the provider’s policy, which limited structured performance review and development.

Training arrangements were inconsistent and did not meet mandatory requirements. Not all staff had completed required training, including the Mental Capacity Act 2005 and the General Data Protection Regulation (GDPR). This reduced assurance staff had the knowledge needed to deliver lawful and safe care.

The provider did not ensure appropriate checks or training for agency staff, who were deployed without consistent verification of right-to-work checks. Agency staff profiles did not list their learning disability and autism-specific training, in accordance with the provider’s policy.

The provider did not effectively assess, monitor or manage the risk of infection. Infection prevention and control (IPC) systems were weak and did not provide assurance that risks were identified or addressed promptly.

IPC governance and oversight did not provide assurance of safe practice. The provider had not completed an IPC risk assessment and could not demonstrate regular IPC audits were undertaken. Cleaning records were limited and did not evidence managerial review, challenge, or quality assurance. The provider was also unable to demonstrate effective oversight of food hygiene and safety.

Cleaning standards were not consistently maintained. We observed that accessible areas, including the loft space, were unclean, one rusty pedal bin, and a slight malodour in the lounge. These observations indicated cleaning processes were not effective in maintaining a hygienic environment.

The provider was unable to provide records to demonstrate that food temperatures were routinely monitored. We found food stored in the fridge that was not labelled with use-by dates. This meant the provider could not be assured that food was stored and managed safely.

During the inspection, the provider took immediate action to reduce some risks, including replacing shower heads and descaling taps. Although these actions reduced some immediate concerns, they were reactive and, at the time of inspection, had not resulted in embedded systems to ensure infection risks were consistently identified, monitored, and managed.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicines management systems did not ensure safe storage or handling. We found medicines were not stored securely, including sedative medication. Food refrigerators were unlocked and used to store medicines. Temperature monitoring was inconsistent and did not record minimum or maximum readings, which reduced assurance that medicines were stored safely and remained effective.

Recording and administration arrangements were unsafe. Medication Administration Records contained multiple unexplained gaps that were not escalated or investigated. For example, 1 person’s records showed that a regular prescribed medication, to be administered twice daily had only been signed for 3 times over 28 days. This increased the risk of missed doses and inconsistent treatment.

Care planning did not support safe or person-centred medicines use. Medicines care plans lacked sufficient detail to guide staff, including missing information about dose, route, or rationale for use. There was a lack of evidence people had been supported to be involved in decisions about their medicines. As and when required medication (PRN) protocols were vague, out of date, and not clearly linked to care plans, which reduced assurance medicines were given appropriately and consistently.

Governance and oversight of medicines were ineffective. The provider had not completed medicines audits, stock checks, or staff competency assessments. These gaps increased the risk of errors and unsafe administration. During the inspection, the registered manager sought external support; however, at the time of inspection, systems had not been implemented or embedded to ensure medicines were managed safely and in line with best practice.