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Inspection Summary

Overall summary & rating


Updated 20 December 2018

This unannounced inspection took place on 10 September, 30 October and 6 November 2018. Our first day in September was cut short as some people living at the home were unwell.

We last inspected the home in May 2017. We found significant improvements had been made to improve the overall quality of the service. However, further improvements were still required to improve the safety of medicines, staff training and competency on the Mental Capacity Act 2005 and the effectiveness of quality assurance procedures. We reported the provider had breached the regulation relating to Good Governance and rated the home Requires Improvement overall.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key question, is the service well-led, to at least good. At this inspection we found the provider had continued to make improvements to the overall quality of the service. Quality assurance checks were completed consistently and were effective in identifying areas for improvement. People, relatives, staff and health professionals gave us good feedback about the registered manager.

Windsor Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Windsor Care Home accommodates 60 people in one adapted building. There were 47 people living at the home at the time of this inspection, some of whom were living with dementia.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People and relatives gave consistently good feedback about the home and the care provided. Staff and visiting health professional gave similarly positive feedback. Throughout our time at the home we observed positive interactions between people and staff.

People said they felt safe living at the home. Relatives and staff also felt the home was safe. Staff had a good understanding of the procedures for keeping people safe. For example, safeguarding and the whistle blowing procedure. They knew how to report concerns and said they wouldn’t hesitate to do so if needed.

Although we observed there was a visible staff presence around the home, we received some mixed feedback about staffing levels. Management felt staffing levels were appropriate. However, the provider did not have an effective approach to monitoring and reviewing staffing levels. We have made a recommendation about this. The provider had effective recruitment procedures to ensure new staff were recruited safely.

Medicines were managed safely. People told us they received their medicines when they were due. Records showed medicines were received, stored and disposed of correctly.

The provider completed health and safety checks and risk assessments to ensure the environment and equipment were safe. There were also up to date procedures to keep people safe in emergency situations. Staff members raised a safety issue with us about using hoisting equipment with certain specialist beds. The registered manager advised that options had been considered but had not been appropriate. However, we noted this issue had not been formally risk assessed to confirm people and staff were safe. The registered manager confirmed a risk assessment would be completed straightaway.

Staff supported people who displayed behaviours that challenge with sensitivity. Staff understood people’s needs and knew the most effective strategies to follow when people were anxious.

The provider had good systems to investigate and monitor incidents

Inspection areas


Requires improvement

Updated 20 December 2018

The home was not always safe.

Risk assessments and other checks were completed to maintain a safe environment. However, staff raised one safety concern which hadn’t been adequately assessed.

There were usually enough staff deployed to meet people’s needs. We noted staff were not always available during the lunchtime.

Staff were recruited effectively.

Medicines were managed safely.

Staff knew how to identify and report safeguarding concerns.



Updated 20 December 2018

The home was effective.

People’s needs had been assessed.

Staff were well supported and received the training they needed.

Staff supported people with the nutritional and healthcare needs.

Adaptations had been made to the home to meet the needs of people living with dementia.



Updated 20 December 2018

The service was caring.

People felt well cared for and said the staff were kind.

People were treated with dignity and respect.

Staff supported people to be as independent as possible.

Care records were personalised to each person’s needs.



Updated 20 December 2018

The service was responsive.

Care plans were detailed and personalised. They had been reviewed regularly to help keep them up to date.

People had opportunities to be involved in a range of activities if they wished.

People knew how to complain if they were unhappy with their care. Previous complaints had been fully investigated.



Updated 20 December 2018

The home had a registered manager. People and staff said management were approachable.

The home had a friendly and welcoming atmosphere.

There were regular opportunities for people, relatives and staff to give feedback about the home.

Quality assurance had improved since our last inspection and was now more effective.