Winchester House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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

The governance systems in place were not robust enough to support the provider to independently identify and address shortfalls to ensure people received safe and effective care at all times.

The provider was in breach of legal regulation in relation to the governance of the service.

This service scored 50 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. Staff did not always understand the challenges and the needs of people and their communities. The provider’s website included information on their commitment and principles. We found some of the wording used on the website by the provider could be more user friendly and informative. For example, stating what the specialised care was. Where staff’s photographs were shown, it did not include a photograph or information on the registered manager.

The leadership and staff told us verbally of their joint vision of wanting to do the best for the people they supported. We found there was culture of working in the same way as they had for years. There were no processes in place to ensure Winchester House was developed or changed in line with current national expectations of person-centred support. For example, ensuring dementia care was reflective of national guidance and good practice in areas such as environment and meaningful occupation. This had impacted on the provider effectively reviewing staffing levels, staff training and environment to ensure people’s changing needs were met. During feedback, the leadership shared how they would be looking to address this, including using reputable sources to keep their knowledge updated in dementia care and current best practice.

The provider said because they were a small service, they worked more as a family and communicated well. When recruiting new staff, they were looking for caring qualities, and staff who would fit in/complement the team.

A person’s relative told us they had chosen Winchester House as it had a good reputation in the community.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience to lead effectively.

The provider’s November 2024 information return told us, ‘our strong leadership ensures that high standards of care are maintained consistently.’ The leadership consisted of the registered manager, who was also the provider and Director, who held the regulatory responsibility for the running of the service. As they did not work full time at the service, they had appointed a care manager. Although in post since 2023, they had not been given a job description to support them in knowing what was expected of them, this was addressed during the assessment after we had alerted the provider to this. At the time of our inspection, there were no effective support systems in place to support the care managers development into this role. Also, where the registered manager’s regulatory knowledge was weak in some areas, such as CQC notifications, it had impacted on them being able to pass on the knowledge to the care manager. The registered manager shared with us the actions they would be taking. This included, taking action to address gaps in their own knowledge, providing more in-person support, and protected time for the care manager to study for a management qualification.

Staff told us they found the leadership approachable and worked well as a team. The registered manager felt the induction/probation period helped them identify any staff who did not reflect their values and therefore would not be given a permanent contract.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People and their relatives, spoke of the benefits of the service which enabled them to get to know the management and staff well. The registered manager and staff’s photographs were displayed in the service. This made it easier for people to know who to speak to if they have any concerns. One person said “Occasionally [registered manager] will come in if short staffed and will help out.” This also enabled people to talk directly to the registered manager who was also they provider if they had concerns.

The service had a complaints policy, and an ‘easy read’ copy which was accessible to people was in people’s bedrooms. The document included information on the external agencies a person could go to if they were unhappy with the way the service had handled their complaint. However, further clarification was needed to inform people which agencies, depending on their circumstance, they could contact. For example, where the service gave details of how to complain to the Local Authority (LA), this was for people funded by the LA, and to CQC, however, CQC do not investigate complaints but encourage people to share their views of the service. The leadership told us they would review the form and act on our feedback.

People said staff fell into their routine, not the other way around. For example, in the morning a person told us staff, “Don’t disturb me, they wait until I ring [call bell].” Another person told us staff, “Come and give me a wash and help with personal care …when I want.” Staff knew people well and could tell us about their individual preferences and daily routines. The provider’s website showed short videos of people, past and present, sharing their views of the service.

The provider who was also the registered manager, valued diversity in their workforce. However, improvements were needed to ensure an inclusive and fair culture for all of their staff, salaried and hourly paid, to ensure their wellbeing.

Staff felt they could speak up, saying they worked well as a team and enjoyed supporting people. During our site visits we heard staff keeping the provider updated over the telephone. However, we found their loyalty to the provider, and dedication to their role, could at times impact on them raising issues which needed to be discussed, such as staffing and workloads. For staff paid hourly, the staff rota clarified what hours they were working, and they were paid if they picked up extra shifts. Where staff were salaried, there was no effective system to monitor the hours they were working. Without having this in place, the provider would be unable to check staff pay was meeting hourly minimum pay guidance, investigate why they were working excessive hours and take action to resolve and ensure staff’s health and well-being.

The provider told us they were addressing these issues through open communication with staff, staff supervision and they would be spending more time in the service.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. Improvements were needed in the responsiveness and oversight of the service to ensure people are constantly receiving a safe, quality service. Not having this in place put people at potential risk.

People and their relatives praised the quality of the service and would recommend to others. However, the provider’s audits and monitoring systems were not robust enough to independently pick up the shortfalls identfied by professionals and during this assessment. This included medicines, care plans, risk assessments, fire safety, staffing levels, infection control, staff skills and recruitment records. The provider had been reactive following our feedback in addressing some concerns quickly, such as fire safety, management of medicines. However, they were not quick to act on ensuring equipment to reduce potential risks for 2 people was put in place.

There was no evidence on how the provider was keeping up their regulatory knowledge, as well as best practice in supporting people living with dementia. This impacted on their ability to be able to effectively delegate management tasks to ensure the changing needs of the people, and regulatory requirements were met. For example, although the service was submitting some CQC notifications, it was not consistent. This was because the task had been delegated, without giving the appropriate training and support.

The provider was receptive to our feedback and told us what action they had taken and considered taking, to drive the required improvements. This included having a knowledgeable person complete a yearly check on the service, the provider felt this would allow improved oversight of the service.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always respond to requests for information from professionals within the requested timescales. Or have a manager contactable on site to discuss issues. We found improvements were needed to improve communication and ensure there were enough delegated management hours, to support staff in achieving this.

The management told us they had a good working relationship with the GP surgery located next door. Health professionals were seen visiting during our visits and 1 person told us they were supported to attend the surgery in person. Care records showed where the service had consulted health professionals to support people’s individual needs. This included hospital clinics, speech and language therapists and emergency services.

The registered manager told us about work being undertaken to support people within the community including visits from a nursery, so the children and people living in the service could interact. The walls showed drawings they had given people. A person also spoke of the “Lovely warm” quilted blankets that a member of the community had donated to the service.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

For people who were at high risk of falls sensor mats were in use in the service to alert staff when the person was getting out of their bed, or their armchair. This enabled staff to attend and help. Where staff had identfied this system did not meet a person’s needs, although professionals had advised on different types of sensor equipment which would be more suitable, no action had been taken to research/purchase the item. Contact with the service following feedback, confirmed the item had now been ordered.

During the inspection, there was a hold up for requested documents, including care plans, due to a faulty scanner. As the documents were not stored on the computer, they could not send them securely to us. Although electronic care planning software had been installed, which would resolve the problem, none of the current people’s care plans had been uploaded. We were told this was due to staff not having the protected time. The provider confirmed they would be taking action to address this.