Windle Court

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 69 (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 fostered a proactive, positive safety culture built on openness and honesty. Staff listened to concerns,investigated and reported safety events, and shared lessons to embed good practice. Systems were in place to learn from incidents and drive improvements.

The registered manager illustrated this approach, explaining,“We had an admission into the home and carried out a pre-assessment; however, the person was very different from what we were told, which led to a safeguarding being raised. We now complete a 72-hour observation form for any new admission to enable staff to clearly document how the person has been in those initial few days. These are then scanned into the system to evidence how we are monitoring the person.”

Lessons were shared in staff meetings and team leader discussions. Staff confirmed they could raise concerns and felt listened to. Records showed changes were implemented following complaints and safeguarding alerts, such as updating continence checks and medicine protocols. This demonstrated a strong commitment to continuous improvement and transparency.

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.

Processes supported safe admissions and transfers.The registered manager said, “We complete a face-to-face assessment,invite families to visit,we start the care plan before the person is admitted then start to personalise the care plan after admission. Family has the opportunity to check the care plan and ensure it is correct and up to date.”

Care plans reviewed during the assessment included detailed risk assessments for falls, choking, and medicines. Relatives confirmed staff arranged transport for people to attend hospital appointments, but some reported missed appointments and poor communication, “Person was due to go for an important scan… then I get a call to say their appointment had been cancelled… communications not very good there.” Despite these issues, most relatives felt their family members were safe and well supported during transitions. 

The provider worked with people and healthcare partners to understand what safety meant to them and how best to achieve it. Staff focused on improving people’s lives while protecting their right to live free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. Concerns were shared quickly and appropriately.

Staff understood safeguarding and how to escalate issues. Comments included,“I would report to my manager and senior, I would write it down, and I would report to CQC if I needed to”
and“I would report to a care team leader straight away, I would document. I would go to the manager.In the staff room there is a Whistleblowing number to use if we need it.”

Training records confirmed staff had received safeguarding training and understood Deprivation of Liberty Safeguards (DoLS) processes. DoLS referrals were made where restrictions applied, and the registered manager monitored them. People can only be deprived of liberty for care and treatment with legal authority, which in care homes is done through DoLS under the Mental Capacity Act 2005 (MCA). We checked compliance with MCA principles and found referrals were completed and monitored effectively.

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.

Staff assessed risks to people’s safety and wellbeing. People’s risk assessments and care plans were regularly reviewed and updated. Staff understood about the risks for each person. The provider made sure staff were trained to support people in a safe way. For example, when supporting them to move, using equipment and with eating and drinking. Staff worked alongside external professionals to review planned care to make sure this reflected best practice guidance for mitigating risks.

During a lunchtime observation,staff explained how some people had chosen to eat in their rooms that day. One person, who was at risk of choking, usually preferred the dining room but requested to remain in their room. Staff respected this choice and ensured their meal was served there. Although the person could eat independently, a member of staff stayed with them to provide discreet supervision and reduce risk, supporting both safety and dignity.

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

Records showed appropriate checks were carried out to maintain the safety of the building. This included in house checks and servicing by outside contractors for gas safety, fire detecting equipment,water temperature and quality and equipment checks. Each person had a Personal Emergency Evacuation Plan (PEEP) outlining the support they would require in an emergency. Fire drills were conducted regularly.

The environment was generally clean and well maintained. A person said, “I have a nice room, and I bought my own armchair from home. It is clean and comfortable.”

The provider acknowledged challenges in maintaining staffing levels but demonstrated a proactive approach to addressing them. Staff were consistently described as dedicated and committed, even under pressure. While some relatives expressed concerns about staffing and its impact on communication and continuity of care, managers responded promptly to feedback. Families noted staff were “thin on the ground” and “rushed off their feet,” which sometimes affected timely updates and follow-up on important matters. Communication was described as needing improvement, with missed opportunities to keep relatives informed about changes, appointments, or health issues. Managers recognised these concerns and took action to strengthen both staffing and communication.

The registered manager and regional operations director confirmed during the assessment an additional evening staff member had been agreed and implemented for Sunflower. This proactive response reflects the provider’s commitment to listening, adapting, and improving the service to meet people’s needs.

Windle Court also promoted people’s involvement in recruitment through its ambassador role. Ambassadors support interviews by meeting candidates and sharing their experiences of living at the home, helping to ensure new staff understand the values and expectations of the service. As one ambassador proudly stated:“I sit in on interviews with the managers… I talk to new people about what it’s like here and what residents need.”

The provider maintained robust recruitment procedures, with fully completed records. Processes included thorough pre-employment checks such as identity verification, references from previous employers, and Disclosure and Barring Service (DBS) checks. These measures supported safe and responsible recruitment decisions.

The provider had systems and processes in place for infection prevention and control (IPC),however these were not always effective in practice. Staff demonstrated good understanding of cleaning protocols, personal protective equipment (PPE) use, and safe disposal. Almost all staff had completed IPC training, and audits were in place.

The home appeared clean and well-maintained during our assessment; however, persistent odours were noted in the Sunflower and Jasmine areas including one lounge with a “strong smell of urine” that did not lessen during the visit highlighting the need for further improvement. The service was without a housekeeping manager at the time of assessment, although recruitment was actively underway.

The registered manager responded promptly with an action plan, including deep cleaning of carpets, furniture, and sensor mats, reviewing continence management, and sourcing odour-neutralising products. These proactive measures, alongside ongoing monitoring, reflected a strong commitment to continuous improvement and maintaining a safe, hygienic environment for people.

The provider ensured medicines and treatments were managed safely and aligned with people’s needs, capacities, and preferences. Staff involved people in planning,including when changes occurred.

We observed good practice, such as a care worker explaining the medicine being administered and offering a drink, followed by signing the Medication Administration Record (MAR). Robust auditing processes supported safe management, and leaders demonstrated strong oversight and compliance with legal frameworks. Medicines were checked daily, and PRN protocols were consistently followed.

A relative praised the approach,stating, “They monitor [person] very well… their medication was all over the place at home, now they have it regular and there are no worries for us.”