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Care Quality Commission report says residents at Winchester House in Minster-on-Sea, Sheerness, not kept safe from risk of choking, constipation, epilepsy and challenging behaviour


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A damning report says residents at a Kent care home were "not consistently kept safe from risks" such as choking, constipation, epilepsy and challenging behaviour.

The stark concerns about Winchester House on Minster Road, Minster-on-Sea, Sheerness, have been raised by Care Quality Commission (CQC) inspectors.

Winchester House on Minster Road, Minster-on-Sea, Sheerness. Picture: Google Maps
Winchester House on Minster Road, Minster-on-Sea, Sheerness. Picture: Google Maps

While they accepted some positive changes had been made by new management, every area when operating this type of service - being safe, effective, caring, responsive and well-led - was identified as “requires improvement” at the home which is run by Achieve Together Limited. It cares for adults aged 65 and under with learning and physical disabilities and can support up to 11 people.

An overall summary of the inspectors’ recently-published report said: “People were not consistently kept safe from risk of harm.

“We found risks relating to constipation, epilepsy, choking and behaviours that may challenge that could have been managed more safely.

“Staff did not always have the right training to carry out their role. Staff had not received regular supervision and appraisal, although the new manager had started to address this.

“Some agency staff had not read people's care plans and some did not know about safety information such as fire safety procedures.”

"We found risks relating to constipation, epilepsy, choking and behaviours that may challenge that could have been managed more safely..."

An Achieve Together spokesman said: "We are clear that the standards of provision delivered at the service at this time fell way below the high standards the people we support expect and deserve, and that we know we can provide. We wholeheartedly apologise for this.

"We have worked immediately to implement a robust action plan which urgently addresses the areas for improvement raised recommended by the CQC - all of which we are taking very seriously. Many of these actions have already been undertaken and embedded."

These include delivering enhanced training, establishing more formal supervisions and senior support across the service and even the region for staff.

"To enhance the living environment at the service so that the provision, not only meets people’s needs but supports them to genuinely thrive, we have redecorated the sensory and activity rooms which the people we support are now enjoying - and we are undertaking further improvements and renovations within the service on an ongoing basis to support this," the spokesman added.

"As part of our action plan, we will be continuing to work collaboratively with those we support, their families, the CQC, the council and other stakeholders to ensure that the provision delivered at the service meets everyone’s shared high standards, and so that the people we support can live happy, healthy and meaningful lives."

The CQC regularly inspects a range of care homes. Stock image
The CQC regularly inspects a range of care homes. Stock image

Other issues raised in the report were some restrictions had not been assessed through the Mental Capacity Act (MCA) 2005 while one person sometimes could not access their room as the door was locked. There was no MCA assessment for this.

While some residents were diagnosed with autism, they didn’t have effective assessments of their sensory needs and a sensory room at the home was not fit for purpose.

Residents did not have end-of-life care plans, either, although the report following two inspections in February added “the manager acknowledged the need for these to be completed”.

The report also said: “People told us they liked their staff and that they were kind and caring.

“One person said ‘The staff are really, really, good. They're always helpful and there if I have a problem.’ We observed some caring support from staff who knew people's needs.

"We are clear that the standards of provision delivered at the service at this time fell way below the high standards the people we support expect and deserve..."

“(But) we expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted.

"'Right support, right care, right culture' is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people, and providers must have regard to it.

“The service was not able to consistently demonstrate how they were meeting some of the underpinning principles of 'right support, right care, right culture'.”

It was reported Winchester House residents needed more support to reach their goals as well.

“Some people were non-verbal but their relatives had not received a copy of their care plan despite asking,” said the report.

“This left people at risk of not having person-centred goals.

"Improvements were needed to ensure that the environment was homely, clean, and well-maintained.”

Inspectors said concerns had been raised over inconsistency due to management changes but all relatives CQC inspectors spoke to were happy with the current manager and his approach.

But breaches in relation to person-centred support, consent, safe care, good governance and staffing were all identified.

“We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety,” inspectors added.

“We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme.

“If we receive any concerning information, we may inspect sooner.”

Winchester House had previously been rated as “good” at its last rating under a previous provider in a report published in December 2019.

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