Windsor Care Centre

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

The service was previously in breach of the legal regulation in relation to safe care and treatment. Improvements were found at this assessment and the service was no longer in breach of this regulation.

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. Systems were in place to review all accidents and incidents and ensure appropriate action was taken to minimise risks to people’s safety and well-being. The registered manager completed a monthly review of all accidents and incidents to identify any potential trends. In addition, more serious concerns were thoroughly investigated and lessons learnt shared with all staff. These measures helped to reduce the risk of accidents and incidents happening again.

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. People told us they felt supported to access healthcare professionals when required. One person told us, “The GP visits once a week, that’s all covered. If I have any issues, the nurses tell them, and they visit me.” The GP completed weekly visits to the service and relatives felt they knew their loved ones well. Where specific areas of concern were identified, the service requested support from healthcare partners. For example, the service had set a goal of reducing the number of falls and skin injuries people were experiencing. Referrals were made to the GP for a review of people’s medicines and weight at an early stage and training was increased. In addition, the local health team supported the service by completing observations of staff practice and offering practical guidance. This joint working led to a significant reduction in falls and skin injuries.

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. Records showed the local authority had been informed of potential safeguarding concerns. Action had been taken to ensure people’s safety, and any changes were discussed with people, their families and staff.

Processes were in place to ensure the Mental Capacity Act 2005 was followed in relation to Deprivation of Liberties Safeguards (DoLS). DoLS applications were submitted to the relevant local authority where restrictions to people’s liberties were in place. This included where people were unable to leave the home without staff support. Where local authorities had placed conditions on people’s DoLS authorisations, these were tracked monthly to ensure they were being fully met.

The provider worked with people to understand and manage risks. 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’s safety and well-being were documented in detail and were known to staff. Records reviewed showed risk assessments were completed collaboratively and maximised people’s independence. Where there had been changes to the level of staff support that one person required, this had increased risks in other areas. Although staff were aware, these risks had not been fully mitigated. The registered manager took immediate action when this was brought to their attention. Detailed guidance was provided for staff in relation to people’s health conditions such as Parkinson’s diseaseand diabetes. This made it clear to staff what support people wanted, any potential concerns and the action they should take. Records showed staff acted upon risks in a timely manner and took appropriate action to keep people safe.

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 records were detailed, organised and up to date. Equipment was checked and serviced in accordance with requirements. Weekly and monthly checks covering fire equipment and water testing were completed and recorded. Where any issues were identified, action was taken promptly to minimise risks.

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. People told us they felt staff met their needs promptly and they did not need to wait for their care. When asked if there were sufficient staff, one person told us, “There are plenty, no waiting, they are coming and going all the time, they want to know how I am. Staff sit and have a chat.”

Staff worked well together and found time to spend with people socially. We observed staff sitting with people, doing puzzles, quizzes and crafts.

Staff underwent an induction into the service which involved shadowing more experienced staff members. In addition, staff completed training in areas including safeguarding, health and safety and person-centred care. Staff received regular supervision which was monitored by the registered manager.

Staff were recruited safely. Robust recruitment checks were completed prior to staff starting their employment. This included gathering evidence such as the staff member’s right to work in the UK, references and a Disclosure and Barring Service check (DBS). These provide information, including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and had processes in place to share concerns with appropriate agencies promptly. The home was cleaned to a good standard and housekeeping staff had clear processes to follow. Staff had access to personal protective equipment, and we observed this was safely disposed of. The laundry area was organised and ensured that soiled, dirty and clean laundry were separated to minimise the risk of cross-contamination.

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 told us they were supported with their medicines safely. One person told us, “They give me (medicines) in the morning and one at night, they are never late.” A relative told us staff being consistent with the timing of their relative’s medicines had led to significant improvements in their health and mobility.

Safe medicines processes were in place. Medicines were safely stored, and the cleanliness and temperatures of storage areas were closely monitored. Medicines administration records were maintained and showed people received their medicines in line with their prescriptions. Where people were prescribed as and when required medicines (PRN) guidance was in place regarding when, how and why this should be administered and the reason for administration was clearly recorded. Where people’s medicines were administered covertly this had been assessed and guidance agreed with relevant professionals. Staff received training in medicines administration and their competency assessed.