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Inspection Summary

Overall summary & rating


Updated 1 February 2019

This inspection took place on 16 January 2019 and was unannounced.

Windsor House is a residential care home for up to fourteen adults with a learning disability. At the time of the inspection there were eleven people living at the service.

Windsor House is a ‘care home’. People in care homes receive accommodation and 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 accommodation was spread over two floors of a converted house in a residential area. There was a large kitchen, a lounge and a dining room. People living at the service had a range of learning disabilities. Some people also required support with behaviours that challenged and physical disabilities.

At the last inspection the service was rated overall as requires improvement. In that we found that activities for profoundly disabled people required further development. And there had not been enough time for the new manager to embed improvements at the service. However, there were no breaches of the regulations. At this inspection we found that the service had improved, and the service is now rated Good.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

The service had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Risks to people had been assessed. There was clear and detailed guidance for staff to enable them to minimise risks. People’s needs were appropriately assessed before they moved to the service. These assessments were used to plan people’s support. Medicines continued to be managed safely and people received their medicines on time and when they needed them.

There were systems in place to keep people safe and to protect people from potential abuse. Staff had undertaken training in safeguarding and understood how to identify and report concerns. Staff had regular discussions with people about their safety to protect them from the risk of abuse.

Staff knew how to keep people safe from the risks of infection and took the appropriate actions to do so. The service was clean and free from odour. The environment had been adapted to meet people’s individual needs and was personalised to reflect the people that lived there.

There were sufficient numbers of staff to meet people’s needs and support people effectively. Staff had the training, skills and knowledge they needed to support people with learning disabilities. Spot checks were carried out to monitor staff performance and staff had regular supervision meetings and annual appraisals. New staff had been recruited safely and pre-employment checks were carried out.

Peoples support was personalised to them and met their needs. There was information on people’s goals, preferences and their plans for the end of their life. Support plans were reviewed regularly and updated when their needs changed. People’s support records were complete and up to date and the registered manager regularly audited the service to identify where improvements were needed.

People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible and were involved in decisions about their support.

People continued to be supported to maintain their health and wellbeing. Where people needed access to healthcare services, this was in place. When people needed to go t

Inspection areas



Updated 1 February 2019

The service was safe.

Risks to people and risks from the environment were assessed and there was clear guidance for staff to minimise risks.

There were enough staff available to meet people's needs. Staff were recruited safely.

People were protected from the risk of abuse and improper treatment.

Medicines were safely managed and people received their medicine as prescribed.

The service was clean, tidy and appropriately maintained and people were protected from the risk of infection.

Lessons were learned when things went wrong and learning was shared with staff.



Updated 1 February 2019

The service was effective.

People�s needs were assessed and used to plan their support.

Staff had the skills, knowledge and training they needed to support people. Staff were appropriately supervised.

People were provided with the appropriate support to eat and drink safely.

People had access to healthcare professionals when they needed them.

The building was appropriate to meet people�s needs.

The provider followed the principles of the Mental Capacity Act (2005).



Updated 1 February 2019

The service was caring.

Staff were kind and caring and treated people with compassion.

People were supported to express their views and were involved in decisions about their own care as far as possible.

Staff provided people with support to maintain their dignity and privacy.

People were supported to increase and maintain their independence.



Updated 1 February 2019

The service was responsive.

People's support plans were personalised and contained information on how people liked to be supported.

People were supported to engage in meaningful activities of their choice.

There was a complaints policy in place and people and their relatives knew how to complain if they chose to do so.

The service was not supporting anyone at the end of their life. However, there were plans in place should they need to do so.



Updated 1 February 2019

The service was well led.

Regular audits were undertaken of all areas of the service.

Staff were happy in their role and felt well supported by the registered manager and that their views were listened to.

There was a positive culture at the service.

Feedback about the service had been sought from people, staff, professionals and relatives.

Staff and the registered manager were aware of their roles and responsibilities and notifiable incidents were reported to CQC.

The registered manager worked in partnership with other relevant organisations and attended meetings with other registered managers to share ideas and best practice.