SINGAPORE – A year after it had cleaned up its act when it was caught out for health and safety lapses, Windsor Convalescent Home was flouting the rules once again.
It lost its licence due to serious lapses that put resident safety at risk, and for failing to ensure proper infection control, among multiple issues. The home has been given four months to transfer residents to other nursing homes.
The Ministry of Health (MOH) told The Straits Times that an audit in December 2024 had uncovered non-compliance at the Pasir Panjang home, such as lapses in clinical and nursing care, and medication management.
By April 2025, these had been assessed to be rectified, said an MOH spokesman. However, it was still concerned with the home’s multiple non-compliances.
So MOH placed it under close monitoring to ensure the changes were fully implemented and sustained.
But the changes were short-lived.
The MOH spokesman said the latest audit in April revealed that the changes were not sustained, and that there were a number of repeated violations.
“There were extensive non-compliances, indicating serious and systemic lapses in resident safety, clinical and nursing care, and infection control practices,” he said.
These were compounded by a lack of control, governance and oversight by the home’s key office-holders.
For instance, the home had failed to conduct appropriate reviews for residents in areas such as falls, pressure injuries and weight loss.
It also failed to follow up on or stick to resident care plans, and managed medication poorly, such as by omitting medication or giving them in the wrong amount, and using expired medicines.
MOH said the home failed to provide adequate basic care to residents such as basic grooming and did not provide appropriate nutrition to residents based on their individual needs.
Food ingredients for the preparation of meals for residents were also found to have expired.
It also failed to implement infection prevention and control measures, as well as ensure hygiene and sanitation in housekeeping processes.
This resulted in the home losing its licence and was given four months to transfer its residents to other nursing homes.
Windsor Convalescent Home, established in 1999, was licensed to operate a 45-bed nursing home. There are currently 25 residents in the home.
MOH was unable to comment on whether the lapses had caused harm to any of its residents.
But the ministry revealed that it is conducting investigations and will take enforcement action as needed.
According to Accounting and Corporate Regulatory Authority (ACRA) records, there are two appointment holders who are legally responsible for running the home and maintaining its corporate governance.
ST has tried reached out to them for comment.
The MOH spokesman reiterated that the interim care team from Vanguard Healthcare, deployed from June 18, had put in place necessary resources to ensure safe care and smooth operations, until the residents have been transferred to other nursing homes.
While staff from Vanguard Healthcare would ensure that no new residents are admitted before the home’s licence is revoked on Oct 30, its spokesperson said it will work with Windsor Convalescent Home’s staff to ensure all residents receive safe and appropriate care.
Some family members of residents said they learnt about the situation through news reports.
A 71-year-old woman, who wanted to be known only as Linda, said she found out about the home having its licence revoked when her son told her about the news in the media.
Linda, whose 96-year-old mother is a resident at the home, said she had picked the place because it was close to her own home.
“When I called, I was told AIC (Agency for Integrated Care) would be in touch next week,” she told ST.
“Also, my mother has not left the nursing home in the entire year she has been staying there. Being wheelchair-bound and since there is no lift down from the second floor, she is afraid. I wanted to bring her home, but she didn’t want to go. She said she was scared to fall down while being brought down the stairs,” she said.
The home is on the second floor of the building, while a temple occupies the ground floor.
ST understands that GentleFoods, a Singapore-based social enterprise that specialises in nutrient-dense, texture-modified meals for individuals with swallowing difficulties, will be providing food to the home from June 22.
There is a total of 93 nursing homes in Singapore, according to the AIC.
Based on information online, residents at the Windsor Convalescent Home are considered private clients who do not receive government subsidies. The monthly cost is around $3,500 to $5,500.
Licences for nursing home services are governed under the Healthcare Services Act (HCSA), which was enacted in 2020 to replace the Private Hospitals and Medical Clinics Act.
HCSA’s regulations on nursing home services kicked in from Dec 18, 2023. One key change is the enhanced governance framework which ensures greater oversight to better safeguard patient safety and welfare.
New requirements include appointing a clinical governance officer to oversee the clinical aspects, and setting up a quality assurance committee to monitor, evaluate and review resident safety and clinical quality issues.
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Additional reporting by Jemima Ryan