Windsor Court Residential 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has

remained good.

This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Records of incidents and accidents were completed and the management team reviewed these to identify any themes or trends. A staff member told us, “Incidents are investigated thoroughly and fairly, with a focus on resident safety, learning, and preventing recurrence rather than blame. I receive feedback through debriefs, handovers, and team discussions, which helps me reflect on practice, understand lessons learned, and contribute to improving the quality and safety of care.”

Staff told us they felt confident to speak up if anything went wrong so it could be corrected accordingly.

Staff received the appropriate training to be able to undertake their roles effectively. Staff told us they felt listened to and valued and could approach the registered manager at any time.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service had effective and well-embedded systems and pathways in place to keep people safe while promoting their independence, rights, and choices.

People were assessed before they moved in. Staff worked in conjunction with the person, relatives, the current care provider and other professionals. This ensured the person’s needs could be met by the service, and compatibility with existing people was carefully considered to ensure people were suitable to live in the same environment and minimise the risk of any conflict. Care records confirmed people had access to a range of health and social care professionals. Assessments undertaken by professionals were documented in individual files and, where needed, a care plan was put in place.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People were safe from harm and abuse. Safeguarding processes were in place to record concerns and notifications to the local authority and CQC were made appropriately. A relative told us, “I have absolutely no worries about [person’s] safety and we see the same staff within the home even after two years. We get updates via a phone call or in person and we’ve now got a WhatsApp group chat on social media which keeps us informed.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes/hospitals, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people were assessed and plans put in place to reduce the chances of these occurring. People were encouraged to take managed risks to maintain their independence, for example in moving around the service by themselves and going on outings. Assessments were regularly reviewed to ensure people’s safety.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

We found the service environment was safe and well maintained. Equipment was tested and serviced regularly and repairs completed when needed. Checks of the safety of the home environment, such as fire safety and water safety, were completed regularly, which helped ensure people were protected from the risk of avoidable harm.

Staff took part in fire drills, so they knew what to do in the event of a fire. People who used the service and relatives commented positively on how clean the premises was.

The registered manager made sure there were enough suitably skilled, competent and experienced staff deployed to meet people’s needs safely and effectively. People and their relatives told us staff were available when needed and had sufficient time to provide support. Staffing levels were monitored and maintained through planned rotas.

Safe recruitment processes were followed, including the completion of appropriate pre-employment checks before staff commenced their roles. Staff received induction, mandatory training and ongoing development opportunities to equip them with the knowledge and skills required to support people safely. Regular supervision and support enabled staff to reflect on their practice and maintain high standards of care.

Staff were competent, knowledgeable and skilled; they carried out their roles effectively. Staff had completed an induction and training programme. People and relatives thought there were enough staff on duty to meet people’s needs. A person said, “There are enough staff and they are very good.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The home was clean and tidy. The provider had policies and training to support good practice.

The registered manager and staff made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

There were arrangements in place to ensure people received medicines in a safe way. Medicine administration records and medicine care plans provided information to ensure people received their medicines safely as prescribed. Staff responsible for administering medicines were trained to manage medicines safely. Everybody told us they got their medicines on time.