Windsor Care Centre

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 requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The service was previously in breach of the legal regulation in relation to the governance of the service. 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 registered manager 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. People and their relatives told us they felt there was a positive culture and the home ran well. One person told us, “It all runs well. It’s better since the new manager started.” One relative said, “It all goes very smoothly. I’m happy overall with everything here.” They went on to give an example about staff being helpful and accommodating.

The registered manager told us they were committed to empowering staff to improve the outcomes for people living at the home. They told us, “When I started here staff were more task focussed. We have increased staff training and empower them, so they now think outside the box. So, for example, staff are going out for walks with residents all the time as they know they will enjoy that.” They added, “Staff saw themselves as ‘just carers’ I want them to understand the skills they have.” The registered manager had developed systems to recognise and reward staff for the support they provided. This included the Little Gem award where people nominated a staff member each month who had gone above and beyond expectations in their role.

The provider had inclusive leaders 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. Staff we spoke to told us they felt listened to and described the registered manager as kind and approachable. They said they felt able to share concerns and request support when needed. We observed the registered manager knew people’s needs extremely well and was able to respond to any requests for information immediately. We observed them chatting with people and staff throughout the day and from people’s responses this was something they did regularly.

The registered manager told us the provider was supportive. They told us, “I can ask for support at any time. I have been allowed the space to grow and develop the service and have ideas to move forward but always run things by them. I see them every week and the staff and residents.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The registered manager had implemented a number of ways to support people, relatives and staff to express their views. These included resident, relatives and staff meetings, annual surveys, one to one meetings and drop-in sessions held with the registered manager. In addition, the service followed the ‘Resident of the Day’ model where staff spent time with a person reviewing their care and listening to any concerns or changes they wished to make to the support they received. Records of meetings and surveys showed an increase in participation and positive feedback with people, staff and residents commenting on the improvements within the home over. Where suggestions were made these were followed up by the management team and action plans implemented. Examples of changes made following people putting forward changes or suggestions included how breakfast was served to avoid delays, the introduction of an Asian style menu available to everyone, the recruitment of additional activities staff and residents’ meetings being held more frequently.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff we spoke with told us they felt the diversity within the workforce was respected. One staff member told us, “We all work together as a family and have respect. This is the manager as well, we are all treated fairly.” The registered manager told us they recognised the diversity within the workforce and planned how to support staff with any specific cultural needs. For example, different religious and cultural festivals were planned through the year to ensure staff were able to take leave at a time which was important to them. In addition, celebrations were held within the home enabling staff to share their culture with others.

The registered manager 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. Robust monitoring and auditing systems had been implemented which provided a good oversight of the service. These included audits of care records, medicines, mealtimes, night care, health and safety and fire procedures. Regular monitoring meetings were held between the registered manager and senior staff where audits were reviewed in addition to accidents and incidents, hospital admissions, clinical concerns, complaints and safeguarding information. Actions were implemented following the meetings which were assigned to relevant staff. The system provided a good oversight for the registered manager who was able to monitor and review concerns and improvements to the service people received.

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. The registered manager had a transparent approach to working with health and social care partners. Where people were staying at the home on a short-term basis information regarding their needs and preferences were shared to help plan for their next step.

Partnerships had also been developed in the local area. The service had made links with 3 different churches in the area who all visited the home regularly. A local school and 2 colleges also visited and arranged events such as parties for people. The residents meeting minutes showed these events were much appreciated by people.

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. There were systems in place to monitor quality and inform learning and improvements. These included quality assurance monitoring, implementing champions from within the staff team, accessing a range of training to support staff skills and appointing resident champions to advocate for people and the service. This demonstrated a proactive approach to ensuring the service continually developed and improved.