Windsor Court

Updated 5 May 2021

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by two inspectors and one specialist advisor. An Expert by Experience made telephone calls to relatives. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Inspection activity started on 24 March 2021 and ended on 09 April 2021.

Service and service type

Windsor Court is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. This information helps support our inspections. We used all of this information to plan our inspection.

The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

During the inspection

We spoke with staff on site and via telephone. We spoke with the registered manager, the area manager, unit manager, registered nurses, nursing assistants, senior care assistants, care assistants and domestic staff. We reviewed a range of records. This included eight people’s care records and multiple medication records. We looked at three staff files in relation to recruitment. A variety of records relating to the management of the service, including policies and procedures were reviewed. We made telephone calls to nine relatives.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data, rotas, dependency tools and a variety of quality assurance records. We received feedback from two health and social care professionals.

Updated 5 May 2021

About the service

Windsor Court is a residential care home providing personal and nursing care to 48 people aged 65 and over at the time of the inspection. The service can support up to 77 people. The service is split into four units across two floors.

People’s experience of using this service and what we found

Systems in place to monitor and improve the quality of the service had not always been effective. Areas identified at this inspection had not been addressed. Improvements were required to ensure effective communication with people’s relatives and staff.

There was not always enough staff to meet people’s needs. Systems in place to assess the staffing levels and rota staff on shift were not always accurate.

The environment was not suitably maintained, for example attention was required to some flooring and carpets.

Records were not always fully detailed or accurate. This included medication records, care plans and risk assessments.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

A new senior management team was supporting the service. They were in the process of auditing the service and making improvements but required further time for these to be embedded and sustained.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last inspection was a targeted inspection therefore the service did not receive a rating (published 18 March 2020). This meant the provider kept the rating of good from the previous inspection published 20 November 2018.

Why we inspected

We received concerns in relation to infection control and from our internal monitoring systems. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvement. Please see the safe and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Windsor Court on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to the maintenance of the building, staffing levels and systems to monitor and improve the quality of the service at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.