Windsor Court Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of the legal regulation in relation to good governance.

This service scored 46 (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 to ensure a shared direction and culture was not fully in place. Although management had taken steps to promote openness and improve the culture within the home, some staff were still unsure whether concerns they raised would be addressed. We also observed inappropriate language used by 1 staff member, which did not reflect the culture expected in the home.

The findings of our assessment did not demonstrate that leaders were always capable and inclusive.

During the assessment we identified shortfalls across the service, examples of which are detailed throughout this report. Leadership did not always provide the oversight, direction and support needed to ensure safe, effective, compassionate and person-centred care.

While staff described the registered manager as, “approachable” and “pleasant,” they told us they would like her to be more visible within the service, to provide support and guidance.

Feedback from people and relatives about the registered manager’s availability and responsiveness was mixed. Some people told us they felt the registered manager was responsive and helpful, others reported that issues raised were not always acted upon in a timely manner.

During our visits, we found both the registered manager and regional manager to be very open and receptive. They took our feedback on board constructively.

Whilst a system was in place to support staff to speak up; some staff told us they did not feel confident to speak up or raise concerns, because they were unsure if action would be taken or if they would be supported. One staff member said, “Sometimes issues are brushed under the carpet.” Work had been carried out to address concerns about a closed culture within the service and policies and procedures were in place however, further improvements were required to ensure staff felt supported to speak up. The provider informed us, and our observations confirmed, that “Talk to us” posters with details for the registered manager and senior management were displayed throughout the home. In addition, HR clinics and regular staff surveys were carried out to encourage open communication and help improve staff confidence in speaking up and raising any concerns.

Work was ongoing to improve workplace equality, diversity and inclusion. Some staff told us they did not always feel valued or appreciated. While staff initiatives were in place, feedback indicated that more needed to be done to embed these changes and ensure all staff felt respected and included.

The registered manager told us they were addressing these concerns strengthening support and training to ensure staff felt better equipped and supported in their roles.

An effective system was not in place to ensure clear governance and oversight. We identified shortfalls in medicines management, the provision of equipment, compliance with the Mental Capacity Act, the assessment of risk and the maintenance of records. The provider’s governance systems had either not identified these issues or had not ensured that timely and effective action was taken to address them.

The registered manager had developed an action plan prior to the assessment, and updated it afterwards, to make sure actions were carried out in a timely manner.

Whilst systems were in place to work with partners and external agencies, further action was required to ensure identified actions were carried out in a timely manner and improvements were sustained in areas such as infection control and the provision of equipment.

Management staff were working with the local authority and external professionals to make improvements and address the identified shortfalls. An action plan was in place to guide and monitor the required improvements.

Systems to learn from incidents, complaints and safeguarding concerns were not fully effective. Shortfalls identified in these areas and the assessment of risk, medicines management and environmental oversight meant leaders did not always identify issues or implement changes to improve safety and quality. Further work was needed to embed learning and ensure sustained improvements across the service.