Windsor 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 good. At this assessment the rating has remained. This meant people were safe and protected from avoidable harm.

This service scored 69 (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 had a proactive and positive culture of safety, based on openness and honesty. The management team listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. For example, a person had an increase in incidents of distressed behaviour, the registered manager increased the reviewing and auditing of the incidents to identify patterns, trends or learning with the aim to mitigate and/or reduce the number incidents. This meant there was a culture of learning and taking action, so people experienced a positive outcome from their support. A relative told us they had good communication with staff and were informed of incidents, accidents and of action taken to reduce reoccurrence.

The provider 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. For example, systems and processes were in place to collate personalised information for all new admissions to ensure staff had clear information and guidance on peoples support and care needs. Staff told us people get the opportunity to visit before they move in to see the home and meet staff. The management team shared care plans with staff before people moved in so staff get an opportunity to read and understand their support needs before they move in.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Staff had received safeguarding training, and staff where able to explain how they would safeguard people if they needed too. The management team reviewed all incident records including behaviours of distress or agitation to determine if the incidents needed to be reported to the local authority safeguarding team. The registered manager told us, “If we had a major safeguarding incident, which is not very common, we complete a lesson learnt and discuss the incident with the staff team to prevent it from re happening.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Personalised risk assessments where in place to provide staff with clear guidance on how to manage known risks. The staff team knew people well and how to best support people. For example, a person had a personalised positive behaviour plan in place for when they showed signs of distress or agitation. Staff were able to explain what they would do if a person started to show signs of distress, how to they responded was in line with the person’s care plan. Staff could explain the specific triggers people faced and their personalised de-escalation techniques.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Regular environmental checks were completed, for example, fire safety and gas safety checks. There was a maintenance person to ensure all environmental matters were completed. We found bedrooms were personalised.

The provider did make sure staff received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. Staff had been recruited safety. Suitable checks of staff had been completed before they started working at the home. This included references from previous employers and Disclosure and Barring Service (DBS) checks. The provider did not always make sure there were enough qualified, skilled and experienced staff. For example, staff had not completed relevant mandatory autism training. The provider told us they have organised for all staff to complete this training. We found there was enough staff to meet people’s support needs. A relative told us, “There are enough staff, and I know a few of them.”

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 home was clean and tidy. There was a cleaning schedule in place for staff to follow. A relative told us, “The house is clean, tidy and well maintained.” Staff had completed infection, prevention control training and there was a policy in place for staff to follow in event of an outbreak.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. For example, supporting information to assist staff in administering medicines that had been prescribed on an ‘as required’ basis were in place, however the information about when to specifically administer these medicines needed to be more detailed. Furthermore, the provider did not have a clear and robust policy for homely remedies. This meant there was a risk of harm from unsafe medicine management. The provider took immediate action and made changes to their homely remedies process during our visit. We found processes were in place for the timely ordering and supply of medicines. Medicines administration records showed people received their medicines as prescribed. Medicines were stored securely. Medicines were reviewed regularly by healthcare professionals and the outcome of those reviews were recorded by the service.