Windsor House

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 remained. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The provider, registered manager and staff team all shared a clear direction of wanting to ensure care was provided safely and in a person-centred way that ensured people’s human rights were respected. We observed staff with a caring attitude and wanting to ensure they provided good care. A relative told us, “I would recommend here to other people.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. The registered manager and provider were open and honest throughout our assessment. Where we raised any concern action was taken. The management team were experienced, capable which provided a well-led service. Processes were in place to ensure the quality of the service was monitored and maintained. The registered manager promoted high standards of care with a vision of delivering high quality person-centred care in the workplace and was fully involved in all areas of the home. Staff spoke about the managers positively. One staff member told us, "I definitely think the managers are capable, experienced and very knowledgeable. I ask questions and always get answers and support.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff and relatives told us they had the freedom to speak up without any fear. A staff member told us, “Yes, we[staff] have the freedom to speak up. Even in supervisions they [management] push us to be honest and ask us what our opinion are and take them into account." Another staff member told us, “Yes, I can raise anything and I'm not worried. They [management] do take action and listen."

The provider valued diversity in their workforce. They had not always worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The management and staff team had not completed equality, diversity and inclusion training. Therefore, we were not assured the provider had the knowledge and understanding to ensure they had measures in place for an inclusive and fair culture. However, staff told us they were treated fairly. One staff member told us, “I have no concerns, I’m treated fairly."

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. The provider had relevant policy and procedures in place to guide staff in relation to best practice and the governance of the service. The registered manager completed a range of audits to review compliance of all aspects of the service, including medicines, safeguarding, care planning and staff training. We were not assured the medicine audit was effective due to the concerns we found during our visit had not been identified before our visit. The management team reviewed audit processes and any learning from this which was shared with the staff team. The service had established means of sharing information with staff, which included including team meetings, and handover meetings. The registered manager was aware of with information was required to be shared with other stakeholders such as the local authority. All staff were clear about their roles and responsibilities. Staff felt respected, supported, and valued by the registered manager. Staff told us they were comfortable to approach the registered manager and felt listened to. One staff member told us, “Yes well organised and managed. I feel everyone knows their role each staff is allocated tasks to complete."

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. There were systems and processes in place to work in partnership with health professionals. The management team told us they had a strong partnership with health professionals to ensure people’s needs were met such as the GP, and Pharmacist. The NHS Pharmacy and Medicines Optimisation completed a visit in 2024, and the management team actioned all their recommendations and actions.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. The provider was transparent and engaged positively during the inspection, welcomed feedback, and were committed to continuously learn and improve care. The provider told us they are moving onto electronic care planning because they wanted to improve care planning, and it would provide oversight of the care people were receiving offsite.