Winchester Heights Care Home

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. This is the first assessment for this service under the new legal entities. This key question has been rated good. This meant people were safe and protected from avoidable harm.

The service was in breach of legal regulation in relation to safe care and treatment including involving people to manage risks and medicines management.

This service scored 63 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff knew what incidents to report and how to report them. The registered manager shared learning with staff through team meetings, supervision and staff communication channels. The registered manager and leadership team monitored the culture in the service by walking round the service twice daily chatting to people, their relatives and staff.

The registered manager told us they received safety alerts from the government, local authority and CQC which informed them of upcoming risks along with themes and trends. They told us they did this to ensure they could take appropriate action to mitigate these risks and communicated this with the wider team to ensure everyone understood.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider had a robust admissions policy in place. The registered manager described how they assessed people to establish suitability and compatibility prior to moving in. They told us, “Following assessment, care plans are completed after 2 days, we organise any equipment needed; we don’t rush to move people in until everything is in place. A staff member is nominated to help them to settle for 2 to 3 hours and to sort out their clothes and medication.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

People told us they felt safe living at the service. The provider shared concerns quickly and appropriately by following the correct process and ensuring these were reported to the relevant agencies. Staff knew how to protect people from abuse and who they could report any concerns to, both internally and externally.

The provider did not always work with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff knew people well. Some people’s relatives told us they were involved in developing their risk assessments and other relatives told us they had not always been involved. People were supported to manage risk while maintaining independence and the service promoted positive risk taking. However, when risk assessments were reviewed and updated, information was not always updated for all the risk assessments. This led to some contradictory or outdated information being contained within risk assessments. The registered manager told us they would review and update them.

During a lunch time observation 1 person was supported to have a drink of juice which they found difficult to swallow and began to cough. Another staff member raised concerns that the person had been given a drink which was not thickened. This staff member stated the person needed fluids thickened to Level 1 at all times. The provider told us; a second referral was made to Speech and Language Therapist (SALT). They told us, “While awaiting assessment, staff took the correct action of raising this with the General Practitioner who agreed to prescribe a thickener, as a precaution until SALT could review the person.” This meant the staff member did not follow the advice from the GP which placed the person at risk of harm.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Several doors which should have been locked to ensure people’s safety, were found to be unlocked on the first day of our on-site visits. We spoke with the manager about this who ensured the doors were locked.

The provider had identified the second floor which accommodated people living with dementia was not dementia friendly. The provider had a service improvement plan in place which identified the second floor would be refurbished in January 2026 to include replacement of furniture, upholstery and carpets. The provider told us they would consult their dementia team throughout the refurbishment process.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs.

The provider was not always working in line with the requirements of Schedule 3 of the Health and Social Care Act 2008. The provider had not always sought satisfactory evidence of staff conduct in previous employment related to health or social care. Where staff had been previously employed to work with children or vulnerable adults, the provider failed to obtain satisfactory verification, so far as reasonably practicable, of the reason why the staff members employment in those positions had ended. This increased the risk that staff unsuited to care work, would be employed in the service.

The registered manager had a training matrix in place which evidenced all staff had completed their statutory and mandatory training. Supervisions were taking place in line with the providers Policy.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff had access to sufficient quantities of cleaning materials and personal protective equipment. We reviewed cleaning schedules which were consistently completed. People and their relatives told us the home was clean, and we observed this.

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

Information to support staff to administer people their medicines was variable. Information about how people preferred to take their medicines was not always available. People’s records included additional information to support staff to administer when required and variable dose medicines. However, some records were not personalised or did not describe how medical conditions were managed with multiple medicines.

Information about the fire risk associated with creams and ointments were not described in the evacuation plan for the service. One person’s medicines were administered covertly. Specialist advice for 1 medicine was it could be crushed. The medicine was a modified release formulation that should be swallowed whole. We were concerned staff had not clarified this with their specialist advisor. We were not assured staff had consistent and easy access to all the relevant information to support people with their medicines.

We reviewed the administration records and daily records for 2 people; each administered a single dose of a medicine to help them manage their anxiety. Whilst staff were able to describe how they would support both people prior to administering the medicines, there were no records to evidence people’s behaviour before or after the medicines were administered. The review of a further person's records indicated that whilst regular physical health monitoring should have been undertaken 4 times a day, there were gaps in the records. Where results indicated further action would be required there was no evidence this had been taken. Therefore, we were not assured staff had good oversight of people’s medical needs. Following the inspection the provider told us they had put a new procedure in place to rectify this.

One person who self-administering their medicines showed us where they stored their medicines, explained how the staff delivered them each month and how staff undertook checks to ensure they were taking their medicines as prescribed.

Medicines, including controlled drugs (CDs), were stored and managed appropriately. Expiry dates and or date of opening were added to most relevant medicines. Records showed medicines were stored at appropriate temperatures.