Complete Care Windsor

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment, we rated this key question Good. At this assessment, the rating has changed to Requires Improvement.

We found the registered person did not have robust quality assurance oversight. However, leaders and the culture they created supported the delivery of high-quality, person-centred care and effective partnership working to support positive outcomes.

The service was in breach of the legal regulation due to failures in governance, including not reporting the death of a service user in line with statutory requirements.

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 had a shared vision, strategy and culture based on transparency, equity, human rights, diversity, inclusion and engagement, and an understanding of the needs of people and their communities.

Managers told us the service aimed to provide high‑quality care for people in their own homes, focused on individual needs. Staff, people and relatives spoke positively about the manager. One staff member told us, “Despite changes the ethos remains the same, which is ensuring the person is central to everything.”

Staff and managers communicated regularly through a range of forums to discuss changes and challenges together. Staff told us they could access the office and speak with managers when needed. Managers provided oversight of induction to ensure new staff understood the service’s values, policies and procedures.

The provider had inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Managers worked with staff to review standards of care. They worked with staff to promote people’s wellbeing, safety and security. Staff gave examples of how managers worked with people and relatives to review support plans and consider different approaches to meet people’s needs.

People and relatives told us the managers maintained regular communication and felt the service was well led. One person told us, “The service is well organised with great expertise. I would definitely recommend them”.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff gave examples of how managers responded to comments and told us, “The management team are good and always available if we have any queries or concerns” and “If we are not comfortable with a situation, they will support us”.

Managers understood processes when concerns or issues would be raised. Information on how to raise complaints was included in policies and procedures. Staff felt confident the manager would respond positively.

The provider valued diversity within their workforce and worked towards an inclusive and fair culture that promoted equality and equity.

Managers worked alongside staff delivering care to better understand challenges staff faced in their roles. Staff completed training and told us they felt included and valued in discussions about improving the service. Policies and procedures promoted staff wellbeing and included guidance to support staff’s spiritual and religious beliefs.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes.

We found the provider did not have quality assurance processes in place, which meant they were unable to identify the shortfalls we found during this assessment. The absence of audits meant managers did not have reliable information to understand whether systems were working or policies were being followed.

The provider lacked effective systems for oversight and monitoring of medicines management. This meant repeated gaps in medication administration records were not identified or addressed in a timely manner. The provider could not ensure that people consistently received their medicines safely.

Information systems were not used effectively to monitor and improve quality. We found missing visit records which meant managers could not rely on data to assure themselves care had been delivered as planned. This increased the risk of missed care and unsafe outcomes. However, managers were organising further training to ensure a consistent approach to record keeping.

The provider did not understand their requirement to notify CQC of the death of a service user. This reduced assurance that events were reported. This was a breach of Regulation 16 of the Care Quality Commission (Registration) Regulations 2009.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff told us managers had a good knowledge of referral pathways to support people to meet their needs. One staff member told us, “If a person needs any adaptations, we can go through it together at the visit and start making changes”.

People and relatives felt the provider worked in partnership with other professionals to meet their needs. Professionals told us, “They have been responsive when contacted, with good response times. They are accessible and timely in their responses, which supports effective joint working.”

Managers maintained relationships with other providers locally and gave examples of how they worked together to co-design a package of care. This meant they could meet the person’s preferences, needs and requirements due to the timing of visits and staffing availability.

The provider did not focus on continuous learning, innovation and improvement across the organisation.

The provider did not have systems in place to carry out internal audits. This meant they were unable to identify areas where care was below the expected standard.
The provider was unable to provide evidence that feedback from people was gathered. This meant that people’s experiences were not captured or used to drive service development. The manager had sent feedback surveys to people when the inspection was announced.
They were open to new ideas presented by staff, although the provider did not routinely complete staff surveys, which limited the opportunity to learn and drive improvement. Managers worked with staff and told us they used group messaging to share information and communicate with each other.
The manager did not hold staff meetings and told us this was due to staff availability and the size of the team. However, one staff member told us they would like more opportunities to meet colleagues and provided examples where accessing peer support through joint working had helped them find unique ways to support people and overcome problems.