Source · CQC inspection
The Withins
Type Social Care Org
Region North West
Last inspected 20 Jan 2023
Location rating: Requires Improvement View location on CQC
Location ratings by domain
Safe
Requires Improvement
Effective
Requires Improvement
Caring
Good
Responsive
Requires Improvement
Well-led
Requires Improvement
Most recent report indexed for actions
Type: Focused inspection
Date: 20 January 2023
Rating extracted from this report: Requires Improvement
Actions indexed:
2 must-do
11 should-do
AI-extracted 17 Feb 2026
Earlier inspection findings
Must-do actions (2)
Must-do action 1 of 2
Must do
Well-led
There was a failure to ensure robust auditing systems were in place to identify shortfalls and act on them to ensure people were safe at all times.
Must-do action 2 of 2
Must do
Effective
There was a failure to ensure staff were suitably qualified, competent and experienced to enable them to meet the needs of the people using the service at all times.
Should-do actions (11)
Should-do action 1 of 11
Should do
Safe
Safe checks of people's liquid medicines needed to be reviewed in order to ensure this process was managed correctly.
Should-do action 2 of 11
Should do
Safe
The protocols did not always provide clear guidance about when these medicines needed to be administered. The protocols required further detail to ensure these medicines could be given consistently and safely, particularly for people who were prescribed medicines for agitation, or a choice of medicines to treat the same condition such as pain relief. Further guidance also needed to be established for people's who were prescribed medicines of variable doses.
Should-do action 3 of 11
Should do
Safe
No checks had been made to make sure it was safe for people to take these medicines and to ensure they would not interact with people's prescribed medicines.
Should-do action 4 of 11
Should do
Safe
Although staff undertook twice weekly spot checks of people's medicines, we found when people had gone out these checks were often missed.
Should-do action 5 of 11
Should do
Caring
The service needed to introduce a bespoke recovery model to ensure progress of people's goals were accurately followed through.
Should-do action 6 of 11
Should do
Caring
During the inspection we identified the lower bedroom windows could potentially compromise people's privacy. Although curtains were in place, an additional safeguard such as a privacy glass or film needed to be considered and discussed with people in these rooms.
Should-do action 7 of 11
Should do
Responsive
The provider should consult current guidance on rehabilitation support models to ensure a clear evidence-based structure is followed.
Should-do action 8 of 11
Should do
Responsive
The format of the care planning system was not easy to navigate, meaning information about people could potentially be missed.
Should-do action 9 of 11
Should do
Responsive
Staff did not complete the daily notes twice daily, as recommend by the provider.
Should-do action 10 of 11
Should do
Well-led
The process for reviewing people's daily care records was informal, meaning there was a risk of not identifying where people had not received appropriate support and instances where daily notes had not been completed.
Should-do action 11 of 11
Should do
Well-led
There continued to be a missed opportunity to complete analysis of incidents to establish if patterns or themes were emerging to prevent or minimise reoccurrence of incidents.