Windsor Court

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 requires improvement. We found breaches in regulation relating to staffing and poor environment. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm. The service is no longer in breach of regulations.

This service scored 75 (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. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.A system was in place to record accidents and incidents. These events were reviewed by the manager so they could act when needed to ensure peoples safety. Staff told us they learnt from when things went wrong. Records showed staff were given the opportunity to discuss any incidents, reflect on current practices and learn from them which helped promote a positive learning culture in the service.

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.Relationships had been built with other health care providers to ensure people had access to the services they needed, this helped to monitor people’s health and wellbeing. For example, the service held a GP round weekly and invited chiropodists and an optician to the service. People had healthcare passports which could be created from the new electronic care planning system, ensuring up to date and relevant information was shared with healthcare providers when needed. This also ensured a smooth transition from care home to hospital for those when their health deteriorated.

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. The provider shared concerns quickly and appropriately.Clear systems were in place to safeguard people. Staff told us they knew how to raise concerns, and they were confident managers would deal with these concerns appropriately. Managers had oversight of safeguarding concerns and worked well with the local authority to resolve any issues identified. The registered manager understood their responsibility when depriving someone of their liberty to keep them safe. The correct applications were in place when needed to help safeguard people.

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.Risks to people had been managed well and care plans were in place to help ensure staff had good understanding and knowledge of how to keep people safe. A new electronic record system had recently been implemented to help improve care records. However, at the time of the inspection we found some areas of risk had not yet been included on the new system. For example, risk assessments for the use of flammable creams were not in place and where people were at risk of financial abuse, this had not been clearly recorded. During the inspection the provider worked quickly to address this, and new records were put in place within 24 hours. There was no impact due to this, because staff knew people well and could clearly explain how to support them safely.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.Maintenance checks were in place to help ensure people’s safety. Staff raised concerns directly with the maintenance team or manager so these could be addressed quickly to resolve any issues. People’s rooms were personalised to suit their tastes, needs and preferences.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.Staff were recruited safely with appropriate checks taking place, they took part in a comprehensive induction and training programme to ensure they were competent and had the right skills to provide safe care. Supervisions were taking place which provided the opportunity to learn new skills and take on more opportunities if desired.A dependency tool was in place which helped ensure the service was staffed to a safe level. We saw staff providing safe, unrushed care during the inspection, however feedback from people regarding the staffing levels varied. Some people told us there was enough staff, while other people told us there was not. Feedback was taken onboard by the registered manager and area director during the inspection, who told us they would continue to review their staffing levels and deployment. Staffing levels had already been increased on the night shift to help alleviate these concerns.

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 service was clean, and domestic staff were on shift daily to help ensure an infection free environment. Cleaning checks were in place to help monitor the cleanliness and staff wore personal protective equipment (PPE) appropriately. When we asked people if the service was clean and well maintained, one person said “Yes, definitely, very clean.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.People received their medication when they needed it, from staff who were confident in managing medication. Training had been provided to ensure staff had the appropriate knowledge and skills. Processes were in place for the ordering and storage of medication. The registered manager had developed audits to check that medication was managed safely.