Windward House

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 Requires Improvement. At this assessment the rating has changed to Good. This meant people were safe and protected from avoidable harm.

The service was previously in breach of legal regulations in relation to safe care and treatment, safe staffing, and safeguarding. The new management of the service had ensured the service was now being delivered safely, and these regulations were now complied with.

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

Incidents and events within the home were now recorded, recognised and then acted on immediately. The service could now effectively monitor for themes and trends. We found the management team were open and transparent and were taking action to drive improvement at the service. For example, during the assessment period a person new to the service left the home briefly without support before returning to the home. The service had taken immediate action to ensure the ongoing safety of this person, through immediate change to keeping internal doors closed, and in the medium term introducing a new key pad lock on a ground floor external door.

The service 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 worked with external professionals to support people.

A person had recently been in hospital for treatment and while in hospital their needs had changed. The service had ensured additional training was obtained for the staff so staff had the skills to meet the person’s needs before they returned to the home.

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

People were now being treated with respect and their dignity maintained. For example, staff were knocking before entering peoples’ rooms.

The provider was now sharing concerns quickly and appropriately with the health and social care system. CQC was receiving Statutory Notifications as required to be sent by the service.

Staff had received safeguarding training, and staff and managers were aware of safeguarding processes to use if necessary.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, 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.

Everyone who showed symptoms of confusion and memory loss had been assessed for their capacity to consent to leaving the home without support. We found all those who used the service and did not have capacity to make informed choices, had a Deprivation of Liberty Safeguards (DoLS) application, or approved DoLS in place.

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

Risk assessments relating to the health, safety and welfare of people using the service were completed and updated. Equipment to help people manage risks safely was being used including bedrails and pressure mats sensors. People were involved in their care planning and risk assessments, where they had capacity to do so. People’s relatives were involved with care planning and risk assessments as they wished.

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

The service was in good repair and felt homely. Since the last assessment, several substantial changes had been made to the structure of the home. The dining room had been more than doubled in size by removing a wall and using the space of what was once a large office. There was now enough seating in the dining room for all those that wanted to eat in the dining room.

The use of the main lounge on the ground floor and training room at the front of the home on the ground floor had been swapped around, creating a pleasant and light ground floor lounge at the front of the building.

The main conservatory lounge had been redecorated as had all the rooms in the presently unused rooms in the wing extension. Many other parts of the service had also been redecorated and there was a good quality of furnishings and equipment throughout the care home. The building was now in a condition to allow the number of people using the service to increase.

The service was clean and well maintained. Peoples’ rooms were personalised as they wanted. For example, one person said, “My room is lovely and clean. I had my family decorate it to how I wanted it.”

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

Almost all care staff (96%) had completed the extensive mandatory training required by the provider. In addition to the required training the registered manager had obtained additional training for staff as necessary, for example, catheter care.

The service was providing individual supervision to all care staff, delivered by the registered manager and the deputy manager. All the care staff had received supervision regularly and within each 3 month period as required by the provider’s policy.

The provider’s staffing level assessment tool was being reviewed every week to take account of the changing needs and increasing numbers of people using the service. Staffing levels were being increased as necessary to ensure peoples’ needs were met.

The staff were deployed effectively to meet the needs of everyone living in different parts of the building. Call bell data showed people were being responded to quickly and their needs were met as soon as possible.

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

Throughout our assessment visits we found the service was clean and people commented positively about how well the cleanliness was maintained by the service.

Personal Protective Equipment (PPE) was fully available to staff, and they were using it consistently during their work. Clinical waste was being appropriately disposed of using specific waste bins. A new system for the management of clinical waste had been introduced since our last assessment which further reduced the potential for cross infection.

The service made sure medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Medication administration was well managed and medication stock levels carefully monitored to ensure the home was not holding more medicines than necessary. The storage of all medicines was tidy and well maintained.

The registered manager had supported the local GP practice to review the medicines of everyone using the service and to ensure the electronic medicines monthly reordering system was operated effectively.

Appropriate directions on the management of all medicines taken as necessary (PRN) were held on the electronic medicines administration system.

Some people were receiving pain relief through medication patches applied to their skin. The location of these on the person’s body was now being appropriately rotated and recorded on the electronic medication administration system.

Where medicines were being delivered to people covertly in their food without them knowing, these arrangements were now in line with the principles of the Mental Capacity Act 2005.