Winslow

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 remained requires improvement: this meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was in breach of legal regulation in relation to environmental concerns.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Environmental checks were completed but identified actions were not always completed within appropriate timescales to ensure risks were managed before safety events occurred. Health and safety assessments for fire and legionella had been completed where actions were identified but we found these actions had not been fully completed as required. Health and safety lessons learnt had been completed from the findings during the last CQC inspection, however, we continued to find concerns in relation to health and safety. Therefore, the learning was not effective. Where people were involved in an accident or incident these had been reported and investigated. Lessons learnt from incidents had been completed and shared with the staff team. Relatives told us they felt supported to raise concerns and were confident they would be treated with compassion and understanding.

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. People had care plans and risk management plans in place which had involved people, healthcare professionals and others involved in their care to ensure staff had reflective guidance on how to provide safe care and support to people.

People were at risk of harm because the risks highlighted to the environment were not always completed when required. For example, a legionella check was completed in April 2024 and identified risk actions to be completed. These actions remained outstanding. This meant there was a risk of water-borne bacteria like legionella that could cause people harm. Relatives told us they felt their loved ones were safe. Staff were aware of their safeguarding responsibilities and knew how to recognise different types of abuse and to report it. There was a process in place for recording and reporting safeguarding incidents.

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. People’s care plans included written guidance for staff to follow regarding their known risks. Relatives told us they felt involved with their loved one’s risk and the staff were aware of people’s support needs. One relative told us, “[Person] has a storyboard to help with communication to minimum the risk.”

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. We found health and safety checks had been completed where required, however, where actions were identified, the actions had not always been completed within the timescales required. For example, a fire risk assessment was completed on 23 September 2022. There was an outstanding action that had been rated medium risk and should have been completed within 3 months of the risk assessment but had not been completed. We also found a legionella risk assessment had been completed on 16 April 2024 which showed 5 actions which remained outstanding, 2 of the actions were red actions that should have been completed within 1 month. This meant people were at increased risk of harm from legionella.

The provider made sure there were enough staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. We observed people were supported by the staffing levels they had been assessed as requiring. The registered manager told us they had reduced the usage of agency staff. This meant people were supported by regular staff who knew them well. Staff had completed training. However, for continence training only 49% staff had completed this. People required support needs around their continence care. The registered manager told us this was due to not all staff having the right email address to access the NHS training. Relatives told us they felt staff were trained. One relative told us, “I think the majority are well trained and quite good. They are good with [family member] and know [them] well.” The provider had ensured recruitment checks had been completed before staff had started work. This included checks with the Disclosure and Barring Service (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. NHS Health professionals completed an infection prevention and control audit in January 2025 and the provider scored 65% which demonstrated minimal compliance. The registered manager told us they had worked through the action plan and completed the actions. Relatives told us, “Kitchen and bathroom cleaned. Last month it was steam cleaned. Toilets are cleaned and I know they use disinfect for the floors.” We observed people’s homes were clean.

Staff who administered medicines had completed training. We found 5 out of 6 staff had received an annual review of their knowledge, skills and competencies in line with the national institute for health and care excellence. However, the staff member who was responsible for the administration of medicines on the day of our visit had not had an annual review of their knowledge, skills and competencies. The registered manager told us it was because they had been on long term leave and it was planned in for the day of our visit. However, the staff member had completed a number of shifts before our visit. When required (PRN) protocols were present for people although theydid not always provide clear written guidance for variable doses for staff to refer to ensure medicines were given as prescribed. For example, a person was prescribed a medicine and it stated take half or one tablet. There was no guidance when half a tablet should be given and when 1 tablet should be given. This placed people at risk from receiving incorrect medicine administration. Medicines were stored safely and securely. Storage temperatures of where medicines were stored had been recorded and within the required ranges. Topical medicines such as prescribed creams were stored securely and had opening dates recorded in line with good practice.