During an assessment under our new approach
About the service
Windrush Care is a domiciliary care agency providing nursing and personal care and support to people living in their own homes.
Who the service is for
This service supports older people, people living with dementia and younger adults. At the time of the inspection, 40 people were being supported with the regulated activity of personal care.
Key findings
We carried out this assessment from 12 June to 30 June 2026. This service was previously rated as good. We carried out this assessment to confirm whether the rating of good remains accurate. This report does not provide detailed information on areas where we found practice continues to meet a good standard. Instead, our findings focus on any areas where the service needs to improve or where we found exceptional practice.
Effective safeguarding systems were in place. Managers and staff had completed relevant adult safeguarding training for their roles and were well-informed about safeguarding practices and how to report concerns.
The provider maintained a transparent and proactive safety culture when incidents occurred which focused on continuously driving improvement. However, incidents were not routinely analysed to identify learning opportunities. The provider promptly addressed our feedback by introducing reports to help identify incident patterns and trends for timely action.
People’s care and support needs were initially assessed, discussed with people and recorded. People’s care records detailed key information including their support requirements, medical conditions and risk assessments. People’s individual risks had been identified and assessed. Staff were given guidance on how to support people to manage and monitor their risks and identify and escalate concerns. One staff member said, “Care plans and risk assessments are detailed and provide clear guidance on how to support people safely and meet their individual needs. They include information about personal care, medication, mobility, risks, preferences, and daily routines. They also explain what changes to look out for and how to report any concerns.”
People were supported by a consistent staff team who knew them well and could respond effectively to changes in people’s needs. Staff were clear about the actions they would take if they found people unwell. They worked and communicated well with people and their relatives to promote positive outcomes and to refer people to health and social care services as needed.
Staff had been trained in medicines management and records demonstrated people received their medicines as prescribed.
People were supported by enough staff who had been safely recruited and had the skills and knowledge to support them safely. Staff completed the provider's induction and mandatory training, received regular supervisions, and their care practices were routinely checked and assessed. This was confirmed by staff. One staff member said, “Spot checks are always carried out.”
We checked and found that staff and management worked within the principles of the Mental Capacity Act 2005 (MCA). People were not subject to unlawful or excessive restrictions; they had choice control and freedom over their lives. Staff had a clear understanding of providing people with choices and respecting their wishes. They described the action they would take if people who lacked capacity refused care. One staff member said, “I give them [people] different option, such as bit of freshen up instead of a shower. If they refuse, I would distract them for a while and think of different way around things and a different approach.” However, we found not all staff had received MCA training appropriate to their role. In response to our feedback, the provider took immediate action to schedule the required training and agreed to review the service's mental capacity assessment procedures to ensure the support of people lacking capacity to make specific decisions aligned with the statutory principles of the MCA.
People and their relatives confirmed staff were punctual and reliable and they were informed if staff were running late. Staff confirmed their rotas provided them with sufficient travel time to carry out their care calls. One staff member said, “If we have found at any time that the time has not been sufficient, we inform the office and they adjust the time as required with consent of person or family.”
There was a positive culture across the service and amongst the established management team. The provider’s values of delivering high quality care for people were known by staff and evident in their practices. One staff member said, “The provider focuses on what is right; they always put the clients first.” Governance systems were used and being developed to monitor the quality of the service. The provider valued feedback from people, staff and stakeholders to help monitor the service and drive improvements.