Winchcombe Place

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this newly registered service. This key question has been rated Good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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.

There were effective systems in place to support learning at a staff team level when incidents occurred. Incidents and accidents were subject to detailed analysis to identify contributory factors and determine any necessary changes to reduce the likelihood of recurrence. Following incidents, staff participated in debrief discussions to review events and promote reflective practice. Where appropriate, incidents were reported to the local authority and the Care Quality Commission (CQC).

One example demonstrated how learning from incidents had helped the provider significantly reduce the number of incidents across the home. This showed the provider was proactive in promoting a positive learning culture, using incidents as opportunities to reflect, learn, and make improvements that enhanced people's safety and wellbeing.

The provider promoted a positive learning culture. Accidents and incidents were reviewed to identify themes, contributing factors and actions. Falls data was reviewed weekly and analysed monthly. When patterns were identified, the provider increased staff oversight in communal areas, added chairs in corridors and sought support from falls, occupational therapy and physiotherapy teams. The recorded number of falls reduced following this work. Staff discussed learning during handovers, meetings and debriefs, and care plans and risk assessments were updated where required. This meant learning was used to reduce repeat incidents and improve people’s safety.

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.

Staff completed pre-admission assessments and hospital passports so that key information followed people into and out of the service. Regular, handover, meetings and multidisciplinary communication meant staff shared information quickly when people’s needs changed.

Relatives told us staff went above and beyond to support people during transitions into the home. One relative explained their family member had been reluctant to move in;, however staff took time to build trust and reassurance rather than rushing the process. They said, “My relative did not want to come to the home. Because of the way the home handled their admission it appeared to be their choice. Staff spent a long time in the car park with my relative and eventually got them to come into the home. Definitely above and beyond. 110%.” This demonstrated how staff supported people through significant life changes in a person-centred way that respected their preferences and promoted positive outcomes.

The provider worked with people, relatives and other teams to maintain continuity when people moved into or out of the home. Pre-admission assessments, care information and hospital passports were used to share key information. Staff communicated changes through handovers and daily meetings. One relative described how staff spent time reassuring their family member, who had been reluctant to enter the home, until they felt able to move in.

This meant the person’s transition was managed at their pace and in a way that respected their wishes.

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. The provider shared concerns quickly and appropriately.

The provider worked openly with safeguarding professionals and promptly shared concerns when people's safety and wellbeing may have been at risk. Relatives spoke positively about the care provided and told us they felt their family members were safe living at the home. One relative told us “When I leave the home I know my relative is safe and secure.”

Staff had received safeguarding training and demonstrated a clear understanding of how to recognise and report concerns. We also observed staff supporting people safely and respectfully.

The provider followed the principles of the Mental Capacity Act 2005 (MCA). The MCA is legislation designed to protect people who may not be able to make some decisions for themselves. Records showed people's capacity to make specific decisions was assessed appropriately and, where required, decisions were made in their best interests.

Appropriate arrangements were in place for people subject to Deprivation of Liberty Safeguards (DoLS). DoLS are legal safeguards used to protect people who lack capacity when restrictions are necessary to keep them safe and receive appropriate care and treatment. Records demonstrated the required assessments and authorisations were in place, any conditions were being followed, and restrictions were reviewed regularly to ensure they remained necessary, proportionate and in the person's best interests.

The provider had systems to identify, report and respond to safeguarding concerns. Staff had received safeguarding training and could explain how they would raise concerns or whistle blow. Safeguarding referrals were made and followed up, and the provider worked with the local safeguarding team. A previous allegation involving unsafe moving and handling was investigated alongside other agencies, records showed lessons were learned. Relatives said they felt their family members were safe. On e relative said, “When I leave the home, I know my relative is safe and secure.” We observed staff supporting people safely and respectfully.

The provider worked 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.

There were clear and comprehensive risk assessments and care plans in place to support people safely while promoting their independence, choice and control. These were developed with people and, where appropriate, their relatives, and were regularly reviewed to ensure they remained effective in minimising risks and supporting positive outcomes.

Staff worked collaboratively with people to identify and manage risks associated with their health, safety and wellbeing. Risk management strategies enabled people to make informed choices and maintain control over their daily lives while reducing the likelihood of avoidable harm.

Where people had reduced mobility, appropriate equipment was provided to support safe movement and reduce the risk of falls. Care plans contained clear guidance for staff on how to support people safely, enabling them to remain active and to continue accessing their local community where they wished to do so.

The provider adopted a proactive approach to supporting people's emotional wellbeing. For example, a designated room provided a calm and therapeutic environment where people could participate in structured activities or spend time independently in a quiet space away from busier areas of the home. This formed part of the provider's approach to helping people recognise and manage feelings of anxiety or distress, while supporting their wellbeing, choice and sense of control.

The provider assessed risks in a way that balanced safety with people’s independence and choices. Care plans included guidance about mobility, falls, nutrition, hydration and emotional wellbeing. Staff reviewed plans when needs changed and sought specialist advice when required. One person told us they had previously worried about falling but felt safer because sensors alerted staff when they got out of bed.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People lived in a safe, clean and well-maintained environment. Relatives consistently told us the home was clean and maintained to a high standard.The environment was well decorated, homely and free from obvious hazards. Environmental audits were undertaken regularly, and any identified issues were addressed promptly.

All servicing records and safety certificates were current. Fire safety systems were maintained, and staff understood their responsibilities in the event of an emergency.

The provider planned for potential adverse events through robust emergency planning arrangements.

Kitchen systems were well managed and food hygiene standards were consistently maintained, achieving a Food Hygiene Rating of 5. Systems for monitoring environmental safety were embedded and regularly reviewed to ensure their effectiveness.

We observed a clean, well-maintained and dementia-friendly environment. Colour, signage, lighting and personalised bedrooms helped people recognise and use different areas of the home. Safety systems monitored fire, gas, water, electrical equipment, window restrictors, lifting equipment and emergency arrangements.

Overall, environmental risks were monitored and acted on, and people lived in a safe and accessible home.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The provider ensured there were enough qualified, skilled and experienced staff to meet people's needs safely. Staffing levels were informed by recognised dependency tools, which were used to assess people's needs and adjust staffing arrangements accordingly. This helped ensure people received timely support from staff with the right skills and experience to meet their individual needs.

Relatives consistently spoke positively about staffing levels and the availability of staff throughout the home. Comments from relatives included,,:

"There always appears to be enough staff around and they have time to talk to me if I need and update on my relative"

"Because everyone at the home works together to watch the residents I feel my relative is very safe"

These comments were consistent with our own observations during the inspection. Staff were visible throughout the home, responded promptly when people required support and were able to spend meaningful time with people and their relatives.

The provider operated robust recruitment procedures to help ensure staff were suitable for their roles. Records showed the provider completed the necessary pre-employment checks, including Disclosure and Barring Service (DBS) checks, employment references and proof of identity, before staff commenced employment.

The provider adopted a values-based approach to recruitment and placed considerable emphasis on developing staff skills and careers. Staff were supported through ongoing training, supervision and professional development opportunities, including the ability to transfer into different roles as their skills and interests developed. Training included dementia awareness and other subjects relevant to people's assessed needs, helping staff to provide safe and effective care.

There was a clear focus on supporting staff wellbeing and creating a positive workplace culture. Initiatives were in place to recognise staff achievements and promote staff engagement, contributing to a stable and motivated workforce.

The registered manager told us the service had not relied on agency staff for over 15 months. This promoted continuity of care and enabled people to receive support from staff who knew them well, understood their preferences and were able to build meaningful relationships with them.

Overall, staff worked collaboratively to provide safe, responsive and person-centred care. People benefited from the consistency, experience and commitment of a workforce that was well supported and focused on achieving positive outcomes.

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.

The provider maintained effective infection prevention and control arrangements to protect people from the risk of infection. During our inspection, the home was visibly clean, tidy and well maintained throughout. Personal protective equipment (PPE) was readily available for staff and was stored and disposed of appropriately in line with current guidance.

Relatives raised no concerns regarding cleanliness or infection control and spoke positively about the environment.

The provider assessed and managed infection risks. Laundry, waste and clinical-waste arrangements were managed safely. Relatives also described the home as clean and fresh. One relative said that when illness occurred, the provider kept families informed and put appropriate precautions in place.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People received their medicines safely and in line with their prescriptions. Relatives told us they were confident medicines were managed appropriately by the provider and did not raise any concerns about medicines management. One relative said,:

"My relative’s medication is reviewed regularly and there have been changes. We are always told and everything is explained."

We observed nurses administering medicines in a calm, respectful and person-centred manner. Medicines Administration Records (MARs) were completed immediately after administration, supporting accurate record keeping, accountability and the safe management of medicines.

People's medicines were reviewed on admission, with staff working alongside healthcare professionals to ensure individual needs were assessed and monitored effectively.

Where required, appropriate arrangements were in place for the covert administration of medicines.

Staff demonstrated a good understanding of time-critical medicines, including those prescribed for Parkinson's disease, and ensured these were administered as prescribed.

Protocols for 'when required' (PRN) medicines were in place and regularly reviewed to support their safe and consistent use.

Regular medicines audits were completed to identify and address any issues promptly. Medicines were administered by trained and competent staff and stored securely. Homely remedies were available to support the timely treatment of minor ailments.

Medicines systems were managed safely. We observed medicines being administered calmly and respectfully, with electronic records completed after administration. Time-critical medicines, controlled drugs, topical medicines and ‘when required’ medicines were checked, and medicines were stored securely. One relative said, “My relative’s medication is reviewed regularly and there have been changes. We are always told and everything is explained.” records for covert administration did always state how each medicine should be given. In response to our feedback, the provider reviewed and updated these records.