Complete Care Windsor

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 changed to Requires Improvement.

This meant some aspects of the service were not always safe, and there was limited assurance about people’s safety. As a result, there was an increased risk that people could be harmed.

The service was in breach of a legal regulation due to failures in the management of people’s medicines.

This service scored 62 (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 did not have a proactive and positive culture of safety based on openness and honesty. They had developed policies and procedures to monitor accidents, incidents and near misses. However, records were not completed, and the provider did not have a system in place to ensure these were reviewed and acted upon. Managers told us people had not experienced serious injuries, although they informed us staff supported people following unwitnessed falls. This reduced opportunities to learn from incidents and continually identify and embed good practice.

Staff understood how to report concerns and told us managers were responsive. Managers told us that when staff reported concerns, they reviewed people’s support plans. The provider demonstrated that the timing of calls and staffing had been increased at times to ensure people were safe.

The provider worked with people and healthcare partners to establish and maintain safe systems of care. They ensured there was continuity of care, including when people moved between different services.

Managers told us that initial meetings with people and families focused on gathering key information and discussed options for support. They then returned to complete support plans and agree on the timing and frequency of visits, in line with people’s goals. Staff told us they read peoples records before visits, and managers confirmed staff understanding where needed. This helped ensure staff were able to meet people’s needs.
The provider used an electronic record system that could be accessed by healthcare professionals. Records clearly referenced where printed information was kept in people’s homes in the event of an emergency. This meant that information was accessible to support safe transitions between services.
Managers gave examples of how the service continued to provide companionship visits when people were admitted to the hospital. This supported the sharing of information and helped people to experience smoother transitions from hospital back to their home.

The provider worked with people to understand what being safe meant to them and the best way to achieve this. The Mental Capacity Act 2005 (MCA) provides a legal framework for making decisions on behalf of people who may lack the capacity to do so themselves. Staff demonstrated an understanding of the MCA and their responsibilities to support people to make decisions wherever possible. One staff member told us, “We give people all the information they need, discuss the potential impact and allow them to make to make their own decision”. Support plans showed people were involved in making decisions that affected them. Records from staff showed that people’s choices were respected.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. When people receive care and treatment in their own homes, an application must be made to the Court of Protection for them to authorise people to be deprived of their liberty. At the time of assessment, no one was deprived of their liberty or had any restrictions placed on them.

Staff were focused on safeguarding people and supporting them to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Staff had completed safeguarding and whistleblowing training. They understood how to raise concerns about poor practice with managers.

The provider worked with people to understand and manage risks by thinking holistically.

People were included in completing each section of the support plan, which detailed strategies to guide staff in supporting them safely. Staff received training to understand and support people’s individual risks.

Staff recorded interactions and escalated concerns to managers. They told us that managers were responsive when people’s needs changed, and how they discussed risks with people and relatives to review support plans.
Managers gave examples of when they had visited and discussed safety with people and options for them to use technology, such as personal alarms. This ensured risks were assessed and staff understood how to meet people’s needs.

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

Managers completed robust assessments to identify and manage potential risks in people’s homes. The provider kept records of the equipment people used and when it had been serviced. Staff and managers described how they supported people to arrange home repairs when needed.

The provider had developed contingency plans for people that included others, such as family or neighbours, who could offer support in the event of an emergency.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support and supervision. They worked together well to provide care that met people’s individual needs.

Staff members were recruited following safe procedures, such as conducting reference checks and Disclosure and Barring Service (DBS) screening. Staff were provided with a detailed induction and ongoing training. Staff received effective support and supervision. The provider ensured staff compliance with mandatory training. Staff completed training relevant to meeting the needs of people using the service.

The provider assessed and managed the risk of infection. Staff told us they had access to personal protective equipment and used it to prevent the spread of infection. They said supplies were available in the office and not restricted.

Staff received training in infection control and followed the provider’s policies and procedures. Service user guides provide detailed information for people on what personal protective equipment staff should have when visiting. Managers told us they spoke to people about ways to reduce the risk of infection spreading during assessments.

The provider did not ensure medicines and treatments were managed safely. We found the provider did not have robust systems in place to support safe medicines management. Medicines audits had not been undertaken to monitor medicines related issues or identify trends and learning.

The processes for maintain accurate records were not effective during the transition between paper and electronic systems. This meant medicines administration records (MARs) completed by staff were not consistently accurate or complete. Managers described steps they were taking to improve documentation.

Staff had received medicines training and understood safer administration practices. However, the provider had not completed competency assessments to confirm staff could administer medicines safely in practice, which increased the risk of unsafe medicines administration.

Managers had completed medicines assessments that reflected people’s needs, capacities and preferences, and MAR charts were updated when required.