Winchester 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. We also checked to ensure people were supported by enough skilled staff, and people were supported to take their medicines as prescribed.

At our last assessment we rated this key question good. At this assessment the rating has changed to 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.

People’s medicines were not always managed safely. Improvements were needed to ensure people were continually supported and had access to a safe environment. Audits and monitoring had not identified the risks picked up during this assessment, including the assessment and mitigation of risks. Lessons were not always being learned and used to drive improvement. Staffing levels were not being monitored to ensure people were always supported by enough staff to provide person centred care.

The service was in breach of legal regulation in relation to ensuring people are consistently receiving safe care.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Lessons were not always learnt to continually identify and embed good practice. For example, accidents and incidents were being recorded on forms however there were gaps in information which did not always demonstrate what action had been taken to mitigate risk. Accident forms showed a high level of unwitnessed falls. There was no overall analysis of the accident/incidents to support the leadership in identifying any themes and/or where they had acted to reduce the risk to the person. People’s care records showed where staff had made referrals to health professionals to support people’s individual mobility needs, but without an analysis, it did not demonstrate if the systems put in place were effective. At the time of feedback, the provider was still looking for a suitable format to use to support them in analysing the information. Leadership told us as part of shared learning from incidents, a memorandum was shared with staff, identifying the shortfall and what actions were in place to prevent a re-occurrence. The provider had held a staff meeting on the 27 January 2025, the agenda included: ‘refreshing ourselves on fire safety, health and safety and infection control.’ A notice on the office wall also reminded staff that they should not use items to hold back fire doors and the correct place to air laundry.

The provider worked with people and healthcare partners; however, improvements were needed in their pre-admission procedures to ensure people’s continuity of care was safely managed. ‘Ambulance forms’ were being used to provide a summary of information about a person to be used by hospital staff, who could be involved in a person’s care. A person’s care records showed health professionals and staff had been working together in monitoring a person’s medical condition to ensure their safety and welfare. People told us prior to their respite stay, management had visited them and carried out a pre-assessment of their needs. One person told us after they had made the decision to use the service, “The owner and manager came,” to see them and their family, which enabled them to ask any questions about the service.



The pre-assessments and care plans of 2 recent admissions were not available for staff to read. The provider’s checks had not picked up that the information was missing. The leadership confirmed the care plans could not be accessed by staff, due to being worked on and locked away on site when no management were present. Staff said they had been given verbal information, and the people were able to inform staff how they wanted to be supported, this was confirmed by the people, who added their goal was to return home after the respite period. However, this was unsafe practice, as it was reliant on people having the mental capacity to inform staff of their needs. The leadership said they were taking action to improve their pre-admission assessments, which were more a check list, and to ensure staff had access to the informaiton and initial care plan.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always share concerns or act on advice quickly and appropriately to support people’s safety and wellbeing. Following concerns raised directly with the CQC in June 2024, the local organisational safeguarding team (OST), as part of their safeguarding investigations, had been supporting the provider to drive improvement through regular ongoing visits. It was found although staff received safeguarding training, checks were not in place to ensure staff fully understood how to relate to practice and report concerns. Safeguarding referrals had not always been made, and/or required notifications sent to the CQC. To address this in December 2024, OST provided training for leadership and staff. A staff member spoke positively of the training, including workplace ‘scenarios’ which they could relate to past and current practice. Improvements were still needed in the leadership’s safeguarding knowledge, such as ensuring appropriate safeguarding referrals and CQC notifications were made. We directed them to the CQC website and OST had been providing additional support.

People told us they had good relationships with management and staff, who they found to be friendly and approachable. We found staff treated people with kindness and respect. One person told us, [staff] “Talk to me.” Another said they, “Definitely,” felt safe living in the service, and knew who talk to if they had a concern. Where people were living with dementia, staff spoke caringly on how they supported individual people when they became anxious to reduce their distress.

The provider did not always work well with people and professionals to understand and manage risks. The audits and systems in place for responding to, and monitoring risk was not effective enough. Improvements were needed to ensure risk management was embedded in staff practice.

Where professionals had identified potential risk and recommended actions to be taken to mitigate risk, the provider was not always quick to respond. For example, where we identified staff had not placed a ‘bumper’ on a person’s bedrails to reduce the risk of entrapment during our first visit on 16 January 2025 it was still not in place when we returned a week later. Nor had the provider acted on the recommendation to try a seat sensor for a person living with dementia, which would alert staff they were standing, to reduce the risk of further falls. Professionals had also raised the same issues with the provider. Although we found the bed bumpers in place on our third visit on 20 February 2025, no action had been taken until after this visit to order a seat sensor. The time taken did not demonstrate a reactive response to ensure people’s safety and wellbeing.

The rubber ferrules on a person’s walking frame had worn through to the metal which made it a slip hazard. This had not been picked up by the provider’s audits and checks. However, these were replaced after we had pointed it out.

Staff were not always being given clear guidance to keep people safe. One person’s care record provided conflicting information regarding the positioning of their bed. The leadership told us the position it was in was correct and they would amend the person’s care records. Another person required 2 staff to use a mobility aid to assist them when transferring. The person told us they felt staff had the right training and skills to support them safely. However, we found no risk assessment on file for staff to read and ensure they were following safe guidance.

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. Improvements were needed to ensure risk management is embedded in staff practice. The provider’s information return [November 2024] told us ‘Staff are vigilant in identifying and mitigating risks.’ However, during our visit on 16 January 2025, we identified concerns around fire safety, kitchen safety, garden environment and management of cleaning fluids which are hazardous to health. For example, the kitchen was not locked to reduce the risks of people accessing the hot water and cleaning chemicals when unattended, the stair banister, which was part of a fire exit, was being used to air laundry and the fire doors to the upstairs rooms: staff accommodation, laundry, freezer room and storage area, which contained potential hazards, were open and held back with items, including a fire extinguisher. The provider’s monitoring systems had not picked up these concerns. We fed back the concerns to the provider and we found the provider was acting on our feedback at our follow up visit on 23 January 2025. The garden did not provide a safe environment which was hazard free. For example, the door to the summer house was hanging off. Following feedback, the provider confirmed work had been carried out in the garden to make if safe, which included removing the summer house. A staff member said the provider “Has done a lot of alterations.” Although there was a large menu choice board with photographs of the lunchtime menu, we found a lack of signage to support people living with dementia.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

Improvements were needed to ensure there were consistently enough staff on duty. One person using the service told us, “Staff say sorry to keep you waiting…they do their best…[need] an extra pair of hands when they are busy.”

There was no effective tool in use to support the provider in setting staffing levels. Staffing levels had remained the same for years when staff told us people were more independent. No consideration was given to increased occupancy levels and people’s changing needs. When the occupancy level had increased from 7 to 9, the staffing levels had remained as 2. This had impacted on staff’s ability to provide the same reassuring support to a person living with dementia we had seen at previous visits. Staff felt the staffing levels were not unsafe, but were aware at busy times people may have to wait for staff support. Staff told us when the care manager was on duty, they provided support if needed. The staff rota showed they were not always available as they were required to cover staff shortages, including covering night duty.

The care manager had been delegated the majority of the management duties. However, there was no formal support system in place to check they had been given the training, support and protected time to carry out their role. The registered manager told us they were taking action to address this. This included protected time for training, increasing staffing levels, and having a more visible presence in the service.

Gaps in employment were not always being identified, discussed and recorded, especially when re-employing staff. The leadership said they would take action to address this and were reviewing their application form to ensure all the information was obtained.

The provider did not always assess or manage the risk of infection to ensure people are consistently supported in a clean and hygienic environment. The provider’s November 2024 information return told us infection control ‘risk assessments are conducted routinely and meticulously updated’. However, we found their monitoring systems had not been robust to independently identify shortfalls in practice. In the kitchen we found cobwebs and we saw that bed pans had not been stored correctly, to reduce the risk of cross contamination. The specialist bath required a more thorough clean. Staff could not confirm if the fabric bathmat was clean or had been previously used. We fed this back to the management, and our next visit showed they had acted on our feedback. The registered manager told us they planned to refurbish the bathroom into a wet room. People told us their bedrooms were kept clean. One person said the domestic, “Came in this morning and hoovered the floor, doesn’t come in Saturday and Sunday.” The staff rota showed domestic cover was provided Monday to Friday mornings, any cleaning outside this time was carried out by the care staff, which took them away from their caring responsibilities. Staff confirmed they had received training, and they had access to personal protective equipment as part of following safe practice.

The provider did not always make sure medicines were being given as prescribed. Staff received training and had their competency checked to ensure they followed safe practice. However, we were unable to reconcile the records for 3 people’s evening medicines. Although staff had signed to say they had given the medicine, a check of tablets showed an overstock. This indicated staff had signed but not given the medicines. This had not been picked up through the provider’s monitoring system. When we brought it to the management’s attention, they reported it to safeguarding. They contacted the people’s GP who advised the missed medicine was unlikely to have caused harm. The provider told us what action they had taken to improve and reduce future risks, and since instigating the changes, there had been, “No mistakes.”

Where people were taking ‘as and required’ medicines, a cross check to the guidance given to staff when they were to be used, identfied 2 missing ones. Staff said they had been place and would ensure they are put back into the folder.

A person’s relative told us they had no concerns, they were aware of the medicines their family member was taking, and staff kept them updated on any changes. Where people wanted to look after their own medicines, systems were in place to support them. One person told us they looked after their own medication as part of retaining their independence and would, “Give staff a reminder,” when they needed any medicines recorded. We saw people being supported on an individual basis, in an unrushed manner, ensuring the person had taken their medicine in their preferred manner.