Winterfell 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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to 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 was a culture of learning from events that had either put people and staff at risk of harm or had caused them harm, to improve the service. We reviewed a log of accidents and incidents which included a robust lessons learnt report, including details of the incident, who the incident has been shared with, and what action had been taken to minimise future risks.

People told us they felt confident that they would be treated with compassion and understanding, and would not be blamed, or treated negatively if they did so.

People living at the service knew who to raise concerns with. One person said “Yes. I could speak to the manager. I've had to raised concerns, yes. They take me seriously and they fix the problems.”

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 experienced a smooth process when they were referred to a different service. Information was shared so people received the care and support they needed, in line with their individual plans. For example, hospital passports if they were being admitted into hospital.

Information was obtained from people, and others involved in their care, about people’s individual needs and risks to their safety. This was used to develop individualised care and risk management plans to ensure people received safe and appropriate care.

The provider ensured that people were accessing appropriate support, working closely with partner agencies. Care plans detailed contact details for professionals involved in people's care. The provider told us how they now felt they had a positive relationship with the GP and worked well with the dementia outreach team.

One person struggled to attend appointments, however a member of staff who they had a trusting relationship with supported them, alleviating some of their anxiety and ensuring they received appropriate support from appropriate professionals.

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 with other agencies, such as the local authority.

There was a clear understanding of the requirements of the Mental Capacity Act (MCA), evidenced within people’s care plans. Staff were able to demonstrate how they put these into practice effectively.

Where applicable, people’s feelings, beliefs and values were considered as part of best interests decision-making. Relevant friends, family, carers and advocates were involved and kept informed of any changes as appropriate.

There was a clear understanding of Deprivation of Liberty Safeguards (DoLS), they were used appropriately and only when it was in the best interest of the person. Where applicable, DoLS conditions were kept under review and adjustments made accordingly.

There was a safeguarding policy in place and staff had received safeguarding training.

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 were supported to be meaningfully involved in managing risks to their safety and wellbeing, with approaches tailored to their individual needs, preferences, and levels of understanding.

Risk assessments were completed, regularly reviewed, and reflected people’s changing circumstances, including mental health fluctuations and cognitive decline. There was a clear emphasis on balancing safety with positive risk-taking, enabling people to maintain control over their lives while receiving appropriate support. For example, one person wished to go on a trip to another part of the country. This was risk assessed, and they were supported by members of staff to fulfil their wish safely.

The environment was safe, well maintained, and met the needs of people living there.

Regular environmental checks were carried out, and any issues were promptly addressed to ensure safety was maintained.

People were supported to personalise their spaces, which contributed to a sense of familiarity and comfort.

Some flooring had been replaced, as well as decoration, making it feel more homely and maintained. We did find that paintwork in some areas required improving, however this was raised with the provider during the assessment and assurances provided that this was being resolved.

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.

There were robust and safe recruitment practices to make sure that all staff, including agency staff and volunteers, were suitably experienced, competent and able to carry out their role.

There were appropriate staffing levels and skill mix to make sure people received consistently safe, good quality care that met their needs, also taking into consideration skill development, people’s aspirations and potential. When people received one-to-one support, staff skills and experience were matched to the needs of the person, whilst considering which staff members people responded to and worked better with.

People told us there was enough staff. One person told us ‘Yes, I think there are enough [staff]’. Another person told us, “If I press my buzzer, I don’t have to wait long, they respond quite quickly’.

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 service maintained effective infection prevention and control practices that were responsive to the needs of people living with dementia and mental health conditions. Staff demonstrated a clear understanding of the importance of maintaining hygiene standards while supporting individuals in a way that respected their dignity and personal routines.

Audits and monitoring systems were in place to ensure compliance with guidance. When discussing how the home was maintained with one person, they told us, “Oh yes, the room is always cleaned. I look after myself to some degree, but they are good that way.”

We found some broken bins which we raised with the provider. They took immediate action and ordered new bins the same day and provided evidence.

All staff had received infection control training, however a few staff members were overdue a refresher on this according to the provider’s training file.

Staff understood the importance of food safety, including hygiene, when preparing or handling food. They follow required standards and practice.

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.

Staff demonstrated a clear understanding of the impacts of medicines, and worked closely with healthcare professionals to ensure prescribing was appropriate, regularly reviewed, and tailored to individual needs.

Where people lacked capacity, decisions were made in line with the Mental Capacity Act, with input from families and advocates to ensure best interests were upheld. Medicines were stored securely, administered safely, and monitored for effectiveness and side effects.

Some people were prescribed PRN (as required) medicines. We saw appropriate and person centre protocols were in place for these. We observed a staff member responsible for medicines, speak with people and ask if they required their as required medicines in an appropriate manor, ensuring those who had capacity to make such decision remained in control.