Windsor Court Care Home

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 inspection we rated this key question requires improvement. At this inspection the rating has changed to good. This meant people were safe and protected from avoidable harm.

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 service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Lessons were learnt across the service and the providers locations. People told us they were involved in their care; the staff worked with people following an accident or incident to prevent a recurrence. The registered manager undertook analysis of all events within the service to identify themes and trends. Learning outcomes within the service had oversight and scrutiny by the provider. Records confirmed reviews were undertaken regularly and in accordance with the providers policy. Health and social care professionals were confident in learning procedures within the service.

The service 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 and their relatives told us they felt the management and staff spoke with external health and social care professionals as required. Relationships between the service and external professionals were established and operated well, feedback collected during the inspection was positive. There were safe systems in place to ensure essential information was shared. The service had a summary of people’s needs and requirements from the providers electronic care planning system. This meant a safe transition between services, such as, admission to hospital.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately.

People told us they felt safe living at Windsor Court Care Home, observations of staff showed they were working in agreed ways to promote safety. Safeguarding procedures were in place, underpinned by the providers policy. Staff knew how to raise concerns within the service and externally, they told us they were confident in the registered manager to follow up and act on the information. Safeguarding training had been completed by staff, including updates. Records showed safeguarding concerns had been raised to the local authority. In addition, notifications had been made to the Care Quality Commission as required. A statutory notification is required by law, to notify us of any significant events, allegation or injury within the service. A relative told us, “I am more than happy with the care. I have no concerns whatsoever.” People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the DoLS, whether appropriate legal authorisations were in place, when needed, to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. The manager had oversight of authorisations.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People told us they felt safe in their environment. Relatives agreed their loved ones were safe in the service and assured by staff presence. Risks to people’s wellbeing and safety had been identified, assessed and measures put in place to reduce them. Records detailed how staff should work to ensure safety, especially about supporting people to move around the service and with using equipment. We observed staff supporting people in safe ways, for example, when using equipment to help them transfer. Staff told us they had enough information about risks to people, enabling them to ensure people’s safety. Environmental and general risk assessments were in place which considered people’s individual needs within the communal environment such as accessing different spaces and fire safety.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People and their relatives were complimentary about the service, describing it as homely. There was an ongoing programme of redecoration, modernisation and refurbishment. Equipment and utility checks were in place and closely monitored to promote safety. A dedicated staff member was responsible for maintenance within the service and carried out checks. There was a programme of works and reminders of expiry dates. The service used external specialists and contractors to undertake some checks particularly where there was need for a specialism, such as gas and fire safety.

The service 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 were supported by enough staff to meet their needs. The provider considered people’s needs and dependency to calculate staffing levels. People said staff came when they needed them. Observations made during the inspection did not identify any concerns about staffing numbers. The service had a thorough induction, shadowing, competency checks and ongoing support processes in place. A staff member told us about their start to working at Windsor Court Care Home and said, “The way they teach you, it makes you feel relaxed.” Staff attended a ‘orientation day’ where they met with other staff, relatives and managers, to learn about the values and mission of the service. Staff undertook training in accordance with good practice guidelines for staff who worked with people requiring care and support. A staff member said, “Everything you need you get; we get training and support. Every day I love to work here.” A recruitment process was in place to ensure the required checks were completed prior to staff commencing their employment. However, this was not in compliance with legislation for the safe recruitment of staff. This meant some required checks had not been carried out, for example, exploration of employment history. The provider had completed other checks such as an enhanced Disclosure and Barring Service (DBS) check for adults. DBS checks provide information including details about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions. The registered manager sought to rectify this shortfall during the inspection.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People and their relatives told us the service was clean and tidy, this included people’s own bedrooms which were cleaned daily. Staff received training in infection prevention and control. Dedicated staff ensured the service was clean, they worked to agreed schedules. We observed the service to be clean and hygienic. Personal protective equipment (PPE) was worn appropriately by staff. Safe infection prevention and control procedures were in place, and this underpinned practices within the service. Infection control procedures and audits were in line with good practice guidance. Staff had plentiful supplies of cleaning materials, products, and PPE. A relative said, “The home is more than clean, staff always cleaning things with their gloves on.”

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

People received their medicines safely as prescribed. If medicines were prescribed to be taken ‘when required’ there was personalised information in place to guide staff when these might be needed. Where prescribed patches were applied to the skin, these were recorded and the site rotated as required. Medicated creams and external preparations were recorded after application . Records showed individual consideration had been given for higher risk medicines such as blood thinning medicines, and flammable topical creams. There were suitable arrangements for ordering, storage and disposal, including for medicines needing cold storage and those requiring extra security. Suitable temperature monitoring was carried out to make sure medicines were safe and effective. Staff had training and competency checks to ensure they gave medicines safely. Any errors or incidents were investigated and reported, so that systems could be put in place to prevent a recurrence. Regular medicines audits took place which identified areas and actions for improvement.