Windsor Court Care Home

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 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 the legal regulations in relation to safe care and treatment and good governance.

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.

An effective system was not fully in place to ensure learning from safety events. Whilst the provider had a process to identify learning, this was not always well used, meaning there were missed opportunities to drive improvements following untoward events.

We identified shortfalls in the assessment of risk, medicines management, infection control, the environment, complaints and safeguarding procedures, which meant leaders did not always identify issues or implement changes to improve safety and quality.

There was a system in place to ensure continuity of care when staff worked with people and healthcare partners to establish and maintain safe systems. This included arrangements for transitions between services. Staff completed pre-admission assessments and reviewed referral information from professionals to confirm they could safely meet a person’s needs before admission. In addition, staff could download a hospital pack from the electronic care planning system, which contained key information to support safe and effective transfers in the event of an urgent hospital admission.

The safeguarding system required strengthening. Concerns had not always been recorded, reported, or escalated to other agencies where appropriate. Staff told us about restrictive practices in the care of 2 people. While staff explained these were in the individuals’ best interests, care plans did not describe these measures, and there was no evidence of professional advice to support them. In addition, 1 person raised concerns about night staff, which they said had not been dealt with. These concerns had not always been recorded or reported.

The home was in organisational safeguarding, meaning the local authority was monitoring the service and supporting them to ensure the correct procedures were in place to keep people safe.

Following our assessment, the registered manager told us she had introduced a process to ensure concerns raised by people were recorded, actioned and reviewed promptly. She also told us that nurses and senior care workers had completed “Responsive approach to care” training as part of the Restraint Reduction Network, which was being rolled out to all staff.

Despite these concerns, most people and relatives generally spoke positively about people’s safety. One person told us, “The fact is, I do feel safe.”

An effective system to assess, monitor and manage risks was not fully in place.

We identified shortfalls relating to medicines management, 1 person’s bed rails, restrictive practices, infection control, the environment and nutrition. Examples of these risks are included throughout this report.

Following our assessment, the registered manager told us these issues were being addressed. Regular medicines audits and checks were being carried out, care plans and risk assessments were being reviewed to ensure accuracy, and staff training was being completed. The individual’s bed rails had been fixed and they were developing a maintenance log to monitor and ensure timely repairs.

An effective system was not fully in place to ensure the environment was safe and equipment was available to meet people’s needs.

We found issues such as unsecured furniture, damaged fittings, uneven surfaces in the garden and a person receiving care in their room where their bed was directly below a damaged ceiling caused by a flood above. Most of these issues were addressed during our visits.

Staff reported insufficient suitable shower facilities on the ground floor. Staff took people upstairs to the male suite if they wanted a shower instead of a bath. They explained it would be more dignified and comfortable for people if a shower room was available on the ground floor.

Concerns had been raised by professionals prior to our visit about the availability of equipment to meet people’s needs. Equipment had now been ordered and, at the time of our visits, 2 people’s equipment was available in the home, however, it was not currently being used as staff needed to undergo additional training to know how to operate it. Staff explained another person was cared for in bed. They stated there was no suitable chair available if the person wanted to get up.

Following the assessment, the registered manager told us action was being taken to address these shortfalls, including obtaining equipment, the completion of staff training, reviewing 1 person’s need for a specialist chair, and progressing plans for a ground floor shower room.

An effective system was not fully in place to ensure there were sufficient, suitably skilled and supported staff deployed.

Staffing levels, skill and gender mix did not always meet the needs of people living at the home. Female staff told us they sometimes felt unequipped to support men who displayed behaviours that may cause distress or pose a risk. The registered manager told us recruitment to increase male staff was ongoing but proving difficult.

We also identified issues with the skill mix of staff. At weekends, there were fewer experienced staff rostered to work, including only one nurse on duty. Staff reported they found this challenging at times, particularly when people required additional support due to distressed reactions or complex needs.

A staffing tool based on people’s dependency levels was used to calculate staffing levels. This indicated that staffing levels were within nationally recognised average ranges. However, staff told us that more staff were required to manage people’s distressed behaviours effectively and to ensure proactive care and support. The provider told us, “The manager and persons in charge have the ability to flex staff and deploy appropriately across the whole home in relation to the needs of the people that they support at any time.”

An effective system was not fully in place to ensure staff were suitably skilled and supported. We identified shortfalls in staff practices in relation to areas such as medicines management, compliance with the Mental Capacity Act, record keeping, and restrictive practices.

Following our assessment, the registered manager told us nurses and senior care workers had completed “Responsive approach to care” training as part of the Restraint Reduction Network, which was being rolled out to all staff.

The infection control system required strengthening.Wear and tear to fixtures and furnishings and poor storage compromised effective cleaning. Sluice areas were untidy and waste management was inconsistent. Similar themes had been highlighted during the local NHS IPC team’s visits in August and September 2025.

Kitchen cleanliness was good. The home had recently achieved a five-star food hygiene rating; however, we observed some uncovered and undated food items stored in dining room fridges.

An action plan was in place and action was being taken to address these shortfalls.

An effective system was not fully in place to ensure medicines were managed safely and in line with best practice. Guidance for ‘when required’ medicines lacked sufficient detail to support safe administration. Recording of topical creams and ointments was inconsistent, with gaps in documentation. Several topical creams were found to have expired beyond six months of opening, and others had no opening date recorded. These were removed during our visit.

Care plans relating to medicines management were not consistently person-centred and contained conflicting guidance. For example, 1 person’s diabetes care plan stated that their insulin regime needed review, but they were not prescribed insulin.

Following our assessment the registered manager told us that the shortfalls were being addressed, and a system of more frequent audits and checks had been introduced to maintain compliance and prevent recurrence of these issues.

Despite these concerns, people and relatives raised no concerns about medicines management. One relative told us, “We come in every morning at the same time and the medication round is always underway whilst we’re here. You can almost set your watch by it.”