Windsor nursing home failed to sustain fixes after 2024 audit found lapses: MOH
The home was placed under close monitoring after a December 2024 audit found non-compliances, but several of the same issues resurfaced in a subsequent audit in April 2026.
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SINGAPORE: Windsor Convalescent Home, a nursing home that was issued a licence revocation on Thursday (Jun 18), had previously been found to have lapses during a 2024 audit, said the Ministry of Health (MOH).
In response to CNA’s queries, MOH said on Friday that the 45-bed nursing home was last audited in December 2024, and multiple non-compliances were discovered.
These included lapses in clinical and nursing care, and medication management, said an MOH spokesperson.
The non-compliances were assessed to have been rectified in April 2025, MOH added.
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Because of the “multiple non-compliances”, MOH placed the home under close monitoring to ensure that the rectifications were fully implemented and sustained, said the spokesperson.
The ministry announced on Thursday that it had issued a notice to revoke the nursing home’s licence to provide nursing home services at its permanent premises in Pasir Panjang.
This was after a subsequent audit in April this year found that Windsor Convalescent Home failed to sustain the rectifications for its past lapses, with a number of repeated findings, said the MOH spokesperson.
“There were extensive non-compliances, indicating serious and systemic lapses in resident safety, clinical and nursing care, and infection control practices in Windsor Convalescent Home, compounded by a lack of control, governance and oversight by its key office holders,” they said.
The home currently has 26 residents, MOH said.
Timeline of lapses
December 2024: MOH discovers multiple non-compliances at Windsor Convalescent Home.
April 2025: MOH assesses that the nursing home has rectified these lapses. However, it places Windsor Convalescent Home under close monitoring to ensure the fixes are fully implemented and sustained.
April 2026: MOH conducts another audit and finds that the earlier rectifications were not sustained, with a series of repeated findings.
May 5: MOH issues Windsor Convalescent Home a notice of intended licence revocation. It gives the home 14 days to make representations.
May: Windsor Convalescent Home requests an extension and is given 28 days instead of 14 to make representations.
Jun 3: MOH receives the nursing home's representations.
Jun 18: MOH issues Windsor Convalescent Home a licence of revocation but this will not come into effect until late October to allow residents time to transfer out. The ministry deploys an interim care team to the nursing home for this period.
Oct 30: The licence revocation will take effect, with Windsor Convalescent Home unable to provide nursing home services at its permanent premises in Pasir Panjang.
The health ministry said the non-compliances were raised to Windsor Convalescent Home during MOH's audits for the nursing home to follow up.
“After the notice of intended revocation was issued to Windsor Convalescent Home, MOH monitored them while reviewing Windsor Convalescent Home’s written representations,” said the spokesperson.
“MOH also advised Windsor Convalescent Home’s personnel to contact MOH with any queries or issues where necessary.”
The nursing home’s licence revocation will come into effect on Oct 30, allowing four months to transfer its current residents to other nursing homes.
An interim care team from Vanguard Health has also been deployed to the nursing home to safeguard the safety and well-being of nursing home residents during this period, said the ministry on Thursday.
NURSING HOME AUDITS
In response to CNA’s query on how often MOH audits nursing homes, the ministry said it conducts “routine audits” to ensure nursing homes’ continued compliance with regulatory requirements.
“MOH may also carry out off-cycle audits where necessary,” said the spokesperson.
“All nursing homes would be audited periodically to ensure continued compliance with the Healthcare Services Act 2020.”
Some of the lapses found at Windsor Convalescent Home during the April 2026 audit included using expired medications, discrepancies in medication quantity and neglecting its residents’ fundamental care needs, such as basic grooming.
“The non-compliances that surfaced from the audit of Windsor Convalescent Home’s practices and protocols were serious enough to warrant the revocation of its licence,” said MOH.
The ministry added that it is conducting investigations and will take enforcement action as needed.
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