Winsford Grange 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

Although there was safeguarding policy in place, not all staff had been following the correct procedures. Concerns had not all been escalated and reported as required. Medication was not always stored or administered safely. People had been left without their prescribed medication which impacted their health and wellbeing. Accident and incidents were not analysed effectively to identify themes and trends to mitigate risks. Not all staff had received training to ensure they were suitable trained and experienced to ensure people's needs could be met safely. Appropriate moving and handling equipment was not available and pressure relieving mattresses were not always set at the correct setting placing people at risk of pressure sores. Poor staffing levels placed people at risk as care could not be provided in a timely manner. One staff member told us, “I am worried about staffing levels, doing my best, but know it's not good enough.” External professional advice was not always sourced when required, for example, nurses were making decisions regarding people's dietary needs without a referral to speech and language therapist to ensure the person received the appropriate modified diet to prevent aspiration. The environment was not clean, and many areas presented as an infection control risk for example, ripped chairs and damaged furniture. Maintenance checks were not being completed as required. Furniture was not always secured to the walls as required. There were insufficient domestic staff deployed to ensure the home was clean and free from malodours.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us they felt safe. Most relatives of people using the service told us they did not feel their relative was safe. One person said, “I do have serious concerns; I raised a safeguarding concern - there was no explanation as to what could have happened” and “you could walk straight through to this unit as the door was left open”. Another relative told us, “I did raise concerns, I went to (name of carer) - she checked, and it was not documented”. Another relative told us “I feel I can manage his care better” and “I shouldn’t have to worry that he’s not up, dressed in clean clothes -10:30 I arrived, he’s in bed in his PJ top”. Relatives told us they could raise any concerns.

There was little or no evidence of a learning culture throughout our interactions with staff. One nurse lacked knowledge and understanding of serious presenting issues which were managed with prescribed medicines. They told us that they had, had conversations with the manager about issues but did not know of anything formalised or recorded. Another staff member said there was no time following incidents, accidents, or deaths for a debrief or to discuss lessons learnt with the team. The manager was supportive but did not have time. Staff were familiar with what to do should there be an incident such as a fall. They described actions to ensure people were safe and received appropriate medical attention should this be required. A nurse said, “Policies are in the office – read them at the start on induction but not read them all, there is insufficient time to read them all but I know where they are”.

Although a Safeguarding policy was in place, this was not effective at keeping people safe. Staff had not been following the correct processes to identify, report, share and act on concerns. There was a failure of staff to report incidents such as bruising, skin tears and falls. This meant the provider did not have an accurate and up to date picture of risk across the service. There were no effective systems in place to ensure incidents and risks were analysed effectively. As incidents were not reported and escalated, there was limited opportunity for staff to learn from accidents and incidents.

People’s feedback indicated they were not always supported to access health professionals when needed. One person told us “yes they ring the GP, optician come here, not seen a dentist since being here” and another person said, “optician is supposed to be coming but I don’t know when”. Relatives told us there were kept informed of referrals, one relative said, “yeah they tell us” and another told us “yes kept informed”.

Evidence identified unsafe systems of care, a lack of managerial overview, poor continuity of care, and poor communication. Staff spoke of their frustrations coping with inadequate staffing and lack of managerial overview. They said they did their best in the circumstances but knew their best was not enough. For example, a nurse said “worried about staffing levels, doing my best, but know it's not good enough”. Another staff member said “Not happy short staffed, regularly shorts staffed" , “We don't actually have a handover”. Staff informed us there was no verbal handover between staff, due to changes in nurses' shift pattern meant they were not paid to come in earlier or stay later to facilitate handover. Another staff member told us, communication had been hampered because there was no verbal handover, information was only shared through written hand over sheets and the PCS system. Which were not always completed effectively.

Partners were concerned regarding referrals not being made to other professionals when they were required or in a timely manner.

Safety and continuity of care was not always treated as a priority throughout people’s care journey. Peoples’ care was not always planned and organised. For example, we saw evidence of nursing staff making decisions about people’s dietary needs without consultation with the relevant external agencies such as the SALT team or dietician.

Most people said they would raise concerns with staff or a family member. Comments included “I would know where to go” and “I’d go to my daughter”. One person said, “I don’t know who to report to”. Relatives said, “the carers are fantastic” and “staff are very good, no complaints about staff but not enough of them”. One relative told us “Yes in the day 100%, I don’t think they are hurting him on purpose, but they are rough and heavy handed at night”.

Staff were familiar with adult safeguarding policies and procedures and knew where to locate them when needed. They were aware of the protections available to whistle-blowers and expressed confidence in reporting concerns, even if it meant going above their manager or, if necessary, outside the agency to the Local Authority (LA).

We observed unsafe moving and handling techniques. This placed people at risk of sustaining injuries. Additionally, people who required assistance with mobilising did not consistently receive the support they needed or have their equipment close by. We observed people who required the use of walking aids without access to the equipment.

Systems, processes and practices to make sure people are protected from abuse and neglect were not effective. The provider did not demonstrate a commitment to taking immediate action to keep people safe from abuse and neglect. This included working with partners in a collaborative way. For example, where people had unexplained injuries, often staff did not report and record this consistently. This meant concerns were not shared with the appropriate external agencies.

It was not clear how well people knew or understood their risks to be able to answer this with clarity, as it was not clear whether some people had been involved in reviews of their care. One person told us, “Not seen my care plan. I think they would let me know if something needed changing” and one person said, “I don’t go out of the room on my own, when I had physio I could walk down the corridor if someone walked with me, and if I couldn't walk back, they'd fetch a wheelchair but as they are short staffed I stay in my room”. Some relatives had been informed of changes, however, one relative had not been informed their family member had changed room.

Nursing and care staff spoken with gave competent to answers to questions relating to involving people in their care and managing risk. However, they alluded to inadequate staffing and managerial oversight and how this impacted on their ability to provide care. They also raised concerns about training, including management of distressing behaviours which was all said to be online.

Risk were not always managed. People were left without access to call bells, preventing them from being able to request or receive support they needed or wanted. We observed people trying to stand without mobility aids when they were assessed as requiring them. We observed people looking uncomfortable in bed without support. We observed people who required close observations not receiving this level of support placing them and others at risk.

We were not always assured risk assessments about care were person-centred and regularly reviewed with the person. Peoples’ care records did not evidence that people had been consulted about their risk assessments or their reviews. We were not assured processes were in place to ensure staff had proper handovers. This meant there was a risk that information about risks to people was not always passed on to staff. Where risk had been identified in peoples’ care records, daily care records did not always evidence they had been managed and mitigated. For example, for people who were on regular changes of position, to help maintain their skin integrity, records did not demonstrate this care had been carried out by staff. For another person, who required regular monitoring to manage a specific health condition, daily records did not evidence the person had received the care they required.

People’s feedback indicated the home was not safely maintained. Comments included “not everything works but they fix it,” “garden a mess” and “mirror light flashes past 7 weeks, staff said it’s in the book”. One person told us “I could do with the water being warmer. I'm washed with cold water. Bit of a shock when they give you a body wash”. Relative feedback indicated concerns about people being left alone.

Staff raised concerns about the cleanliness of the home, poor maintenance of the premises and the grounds.

The environment was not clean and presented an infection risk. The walls were dirty with food and drink splashes on them. Some chairs were ripped, some furniture was damaged and prevented it from being cleaned effectively. The grounds were poorly maintained presenting tripping hazards and impeding safe evacuation in the event of an emergency. Window restrictors in some bedrooms were not in place, wardrobes were not always fixed to walls, and fire doors did not always close on their rebates. Appropriate hoist and slings were not available, and pressure relieving mattress pumps were not always set on the correct setting leaving people at risk of pressure sores.

The provider had processes to audit the environment, identify maintenance tasks and carry out required works but these were not adhered to. Weekly room checks were completed however these were not effective due to inaccurate recording. Rooms were recorded as having all wardrobes attached however we found this work had not always been undertaken. There were insufficient domestic staff deployed to ensure the home was clean and free from malodours. The Legionella Risk assessment was out of date and routine flushes had not been carried out since the 10 June 2024 and there was no evidence that water temperatures had been taken monthly, as required. This resulted in the premises being unsafe, unclean, and poorly maintained.

Most people said their call bell was attended to quickly. However, people told us there were not enough staff. People’s comments included “there are lots of changes in staff” and “new staff don’t last”. Relatives told us “there are a lot of changes of staff - not enough of them and long shifts, they don't stop, the ones that are around are good, but they need more” and “some static staff [names staff] however, constant changes”.

Staff told us they were struggling with insufficient staff, including managerial staff, nurses, care staff and ancillary staff. This impacted on their ability to provide safe and effective care. Staff told us the service was “flooded with agency” and “they don’t know what they are doing”. Staff told us having the responsibility of providing inductions to agency staff was taking them away from carrying out their caring responsibility and adding additional pressure. This placed additional pressure on staff having to continuous support agency staff.

There was not an appropriate staffing level and skill mix to make sure people received consistently safe, good quality care that met their needs. We observed people waiting for prolonged periods of time to receive personal care and attending the toilet. We observed people who were visibly distressed, and staff not having the time to comfort or reassure people. We observed meal trolleys being left unattended due to staff providing support to people who required assistance at mealtimes. People did not receive the encouragement required during mealtimes due to staff not being available.

There was no dependency tool to ensure there was appropriate number of staff to meet people's needs safely." The rota was not always accurate, they listed some staff as being on shift when there were not present. Management were not aware when staff were off sick and cover arrangements. We identified there was no chef in the kitchen the following day, management were not aware. There were not enough staff in the laundry and housekeeping leading to challenges in ensuring that people had clean clothes and the environment was clean.

People told us the home was clean, however, one person told us “paper on the floor since this morning, no-one picks it up, 5 or 6 people have been in”. Relatives told us “room not been hoovered for 2 weeks. It's not clean” and “it used to be clean”. All people we spoke to said staff used PPE (personal protective equipment). Relatives supported this by telling us staff use PPE. We observed one room infested with ants, there was no evidence of treatment and dead (flying) ants lay on the floor.

Staff were concerned about the lack of cleaning staff. This impacted their ability to maintain effective levels of hygiene in the home. Staff had received training on infection prevention and control but only online. They reported that stocks of PPE were plentiful and knew what action to take in the event of a person or persons presenting with symptoms of an infectious disease.

There was not an effective approach to assessing and managing the risk of infection, in line with current relevant national guidance. People were not protected as much as possible from the risk of infection because premises and equipment were not kept clean and hygienic. We observed an unclean environment, this included, dirty and dusty skirting boards and windowsills, walls and doors marked with fluid residue, dirty carpets and unclean equipment such as bath chairs. Roles and responsibilities around infection prevention and control were not clear, as there was a lack of domestic staff, and the registered manager's walk arounds were not effective, as they had failed to identify shortfalls in cleanliness.

Processes in place for the monitoring of IPC were not effective. The completed audits did not identify the concerns highlighted in this assessment. Despite bathrooms being out of action the service had scored the bathroom environment 100%. There was lack of consistency with the recording of information.

Most people were not aware of what medication they were taking. People told us they did not always receive their medication. One person told us “they have ran out of it , last week furosemide (diuretic) for about 3 days” and “couple of times they've said they've not got some - say they are waiting for the pharmacy. Painkillers I've been howling in pain - I have to wait a long time for pain relief”. Relatives also confirmed their family member did not always receive their medication. Comments included “they cannot get his medication, they are having trouble getting it, this has been for about 4/5 days” and “I've been told he's ran out of paracetamol once or twice”. This placed people at risk of avoidable harm and discomfort.

Staff involved in the administration of medicines advised that they had completed online training followed by meds competency carried out by the manager in May 2024. Feedback from leaders identified they had found a significant amount of serious issues with medication including numerous medications for people being out of stock which resulted in people not receiving their medication. Nurses were signing for topical creams and thickening agents despite having not administered these and were not aware this was not the correct procedure. One of the senior managers told us that they only discovered serious concerns about the safe management of medicines three days before the assessment, this meant that their previous audits about medicines were not effective in picking up concerns. They also told us they were unaware of which people needed to be given their medicines covertly which meant people may not be getting all the medicines they needed. Policies about medicines management were in place, but they were not always followed by staff. One nurse told us they crushed medicines because they had not realised that the medicines could not be crushed.

The system for ordering medicines was ineffective and people missed multiple doses of their medicines including medicines for the treatment of anxiety, pain, constipation and infections. This placed people 's health at risk". Systems were not in place to make sure medicines were given safely. Medicines that needed to be given with food were given with medicines that should be given after food. There were no systems in place to flag when doses of medicines needed reviewing due to peoples changing weight or swallowing ability. Systems were not in place to make sure people’s diabetes was managed safely. Some people needed to have their fluids thickened and were prescribed a thickening powder to be added to their fluids to prevent them choking. The records showed that people did not always have their fluids thickened safely. Some people needed it be given their medicines hidden in food or drinks, covertly. There was no information available, from a pharmacist, for staff to follow as to the safest way disguise each induvial medicine. Some people were prescribed medicines to be taken ‘when required’ or with a choice of dose. The protocols to support the safe administration of these medicines were either not in place or were not personalised, and there was no information for staff to follow to assist them to decide the most appropriate dose administer when there was a choice of dose. This meant people may not get their medicines consistently and at the time they were needed. Medicines, including creams and injections, were not always stored safely or at the correct temperatures. Waste medicines were not stored securely in line with current guidelines.