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 people were protected from abuse and avoidable harm. At our last inspection in 2019 when this service was owned by another provider, we rated this key question good.

At this inspection, the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulations in relation to safe care and treatment including the safe management of medicines, and staffing.

This service scored 53 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

For example, incidents and events within the home were not always recorded or recognised and then acted on. Therefore, the service could not effectively monitor for themes and trends. However, we found the management team were open and transparent and were taking action to drive improvement at the service.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored. They made sure there was continuity of care, including when people moved from the service. The service worked with external professionals to support the people in the service’s care.

The provider had not worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They had not concentrated on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider had not shared concerns quickly and appropriately.

The service was not always keeping people safe from suffering harm. For example, a person was recorded as being put into clothes that were significantly too small for them to wear. We also saw on a number of occasions staff entering people’s rooms without asking the person if they could come into their personal space. On another occasion, a cleaner entered a person’s room who had significant dementia care needs and was asleep, woke them to ask if they could hoover the room though they did not understand the question, and then continued to hoover the room around the person. These actions did not respect the person’s privacy, and right to be undisturbed when asleep.

The provider worked with people to understand and manage risks with a holistic approach. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service was working with people to understand and manage their risk. Risk assessments relating to the health, safety and welfare of people using the service were completed. Equipment to help people manage risks safely was being used including bedrails, and pressure sensor mats. People were involved in their care planning and risk assessments, where they had capacity to do so. One person said, “I’ve got one (care plan and risk assessments), yes, if I don’t like something they (the staff) will change it for me.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The service was not always in good repair and homely. For example, some furniture was worn and needed replaced and some wallpaper was peeling. The downstairs lounge was cluttered. The downstairs areas used by people with dementia were a lot less homely than the areas upstairs, which were not used by people with dementia. The provider told us about extensive plans to replace furniture and fittings and renovate the building in phases. While each area was being renovated it would not be in use. The provider said carrying out the refurbishment in this way would cause as little disruption as possible to the people using the service.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The service had enough staff, however the provider had not ensured that staff were adequately supervised in how they delivered their work. We could see that some care practice in the service was poor in places and so supervision of staff was important to direct staff in good practice. There had been little individual supervision, in line with the providers policy, in the months before our assessment. However, the new service management had taken action to improve management of the service and was beginning to take action to re establish appropriate supervision of the staff group.

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

The service was appropriately clean throughout our assessment. As the service did not have an enclosed sluice, disposable commode pans were in use to safely manage risk of infection.

Personal Protective Equipment (PPE) was fully available to staff, and they were being closely managed to ensure that it was worn. A formal direction was given to staff at every shift handover to always use PPE.

The provider did not make sure that medicines and treatments were always safe and met people’s needs, capacities and preferences. Some people were not involved in planning of their care.

The service was not always delivering people’s medication in line with current national guidance and best practice. For example, some people were receiving pain relief through medication patches. There were no written directions or records being used in the service about rotating the placement of these patches on a person’s body. It was possible that the person was not receiving the full strength of their medication if the patches were placed inappropriately.

One person did not have the mental capacity to make decisions about their medication. Therefore, the medicine was being delivered to them covertly, in their food without them knowing. Neither a Mental Capacity Assessment or Best Interests process had been followed to protect the person’s rights appropriately under the Mental Capacity Act 2005.