Winfrith House

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 inadequate. This meant people were not safe and were at risk of avoidable harm.

Systems to assess, monitor, and manage risk did not keep people safe. The provider did not consistently identify, assess, or mitigate individual risks, environmental hazards, or infection prevention and control risks.

People’s medicines were not managed safely. We found inadequate storage arrangements, inconsistent temperature monitoring, and gaps in medicines records. There lacked an effective audit programme or staff competency framework to support safe medicines administration. These issues increased the risk of errors or medicines being administered without appropriate oversight.

Safeguarding processes lacked effective management oversight. Safeguarding referrals, outcomes, and follow-up actions were not consistently recorded, reviewed, or tracked to completion. Incident reporting was inconsistent and did not support learning or risk reduction. Although individual staff demonstrated awareness of safeguarding procedures and knew how to respond to immediate concerns, these practices were not supported by effective systems, leadership, or governance.

The provider was in breach of the legal regulations safe care and treatment, safeguarding, and staffing.

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

Care and support were not consistently effective or delivered in line with legal requirements. The provider did not consistently follow the Mental Capacity Act 2005. Mental capacity assessments and best interest decisions lacked decision-specific detail and did not consistently evidence people’s involvement or appropriate consultation with family members or relevant professionals. These were repeat concerns from previous inspections and had not been fully addressed.

Staff were able to recognise changes in people’s health and sought advice from external healthcare professionals when needed. However, gaps in care planning, record keeping, and management oversight limited assurance that care was consistently effective, lawful, and based on best available evidence.

The provider was in breach of the legal regulation consent.

Caring – this means we looked for evidence that the provider involved people and treated them with compassion, kindness, dignity and respect.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were supported and treated with dignity and respect.

People experienced compassionate and respectful care from staff. We observed positive interactions where staff promoted privacy and dignity and adapted their communication approaches to meet individual needs. Staff demonstrated a good understanding of people’s routines, preferences, and communication styles, including the use of key words, gestures, visual prompts, and Makaton.

These approaches enabled staff to provide reassurance and respond sensitively to behaviours that challenged. Interactions were calm, patient, and respectful, which supported people to feel settled and understood during the inspection.

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant people’s needs were not always met.

Care planning did not consistently support personalised and responsive care. Records did not always reflect people’s aspirations, communication needs, or support to access the community. Person-centred care planning was inconsistent, and information was not always clear, detailed, or up to date to guide staff practice.

This increased reliance on individual staff knowledge and reduced assurance people’s needs would be met consistently over time, particularly during staff absences or changes in staffing. Although we observed staff responded appropriately to people’s immediate needs and de-escalated behaviours using positive communication strategies and offered choice. Weaknesses in documentation, review, and oversight limited the provider’s ability to demonstrate care was planned, reviewed, and adapted in response to people’s changing needs and preferences.

The provider was in breach of the legal regulation person-centred care.

Well-led – this means we looked for evidence that service 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 requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

Leadership and governance arrangements did not provide effective oversight. Systems to monitor risks, staffing, medicines, safeguarding, and care quality were ineffective. Audits were absent or incomplete, incidents were not consistently analysed for themes or learning, and action was not taken to address identified shortfalls.

The provider had not addressed breaches identified at previous inspections, which demonstrated a failure to embed learning and improvement. The registered manager’s dual registration across 2 services, combined with limited oversight from the nominated individual, reduced leadership capacity to effectively discharge their legal responsibilities. These governance failures undermined confidence in the provider’s ability to sustain improvement and placed people at ongoing risk of unsafe and inconsistent care.

The provider was in breach of the legal regulation good governance.