Background to this inspection
Updated
28 October 2023
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
The inspection team consisted of 2 inspectors, a pharmacy inspector, a specialist advisor who was an occupational therapist and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
Windsor Care Centre is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Windsor Care Centre is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was a registered manager in post who was leaving. A new manager had been recently appointed who intended to submit an application to register.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.
The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.
During the inspection
We spoke with 8 people who used the service and 1 relative. Some people living in the home could not verbally give us feedback. As such we looked around the home and observed the way staff interacted with people. We looked at 19 people's care records and 11 medicine administration records (MAR). We spoke with 11 members of staff including the directors, manager, nurses, carers, kitchen staff, domestic staff, maintenance personnel and nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.
We reviewed a range of records relating to people's care and the way the service was managed. These included staff training records, 4 staff recruitment files, quality assurance audits, incidents and accidents reports, complaints records, and records relating to the management of the service.
Updated
28 October 2023
About the service
Windsor Care Centre is a purpose-built residential care home providing personal and nursing care for up to 72 people across 2 separate adapted floors. The service provides care to older adults some of whom live with dementia. At the time of our inspection there were 39 people living at the service.
People’s experience of using this service and what we found
Some significant improvements had been made, however, further improvements were still required to ensure people were safe.
We found whilst some aspects of medicines management had improved, other areas needed further improvements. Where people temporarily left the home, the provider did not have systems in place to ensure the continuity of medicines administration. This put people at risk of possible missed medicines. Where people were prescribed when required (PRN) medicines, person specific guidance was not in place to aid staff when making decisions to administer the medicine. Therefore, we were not assured that staff would consistently assess the residents need for PRN medicine administration.
Risks related to fire were not always managed safely. Recommendations made following fire inspections were not always considered or actioned. The provider’s auditing systems were not used effectively to manage fire risks and we identified some missed opportunities where learning could have occurred.
People’s risk of pressure damage was not always managed safely. There was no process in place to ensure mattress settings were checked and were correct. This put people at potential risk of pressure damage.
Whilst some improvements had been made with the provider’s quality assurance systems, we saw further improvements were still required. Quality assurance audits failed to pick up some of the concerns found during this inspection.
We acknowledged the provider had introduced new systems and processes, however, at the time of our inspection we were not assured of their effectiveness. Some of the processes had only been introduced for just over a month.
The provider had made some significant improvements such as staffing, staff training and communication. We saw these changes had made a positive impact on people’s outcomes. Staff genuinely looked happy and focused on making further improvements.
People told us they felt safe living at Windsor Care Centre. Staff knew how to identify and report any concerns. The provider’s recruitment and selection processes in place had improved and were safe.
People had an improved dining experience which offered a variety of appetising food choices that suited people’s preferences. People were supported to meet their nutritional needs and complimented the food at the home.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. However, we saw the provider had identified some recording shortfalls which staff were working through.
The culture of the service had improved and was now open and inclusive, people felt communication from the new manager was good. Staff told us they felt supported and listened to. The manager sought feedback from people and staff and used this to improve the service. The manager and provider were committed to improving people’s quality of life. There was a clear management structure in place and staff worked well as a team. The provider had sought support from a consultancy company with the aim of continuously improving staff and people’s experiences. The provider had better oversight of the service. Staff worked well with external social and health care professionals.
Rating at last inspection and update
The last rating for this service was inadequate (published 11 October 2022). This service has been in Special Measures since 11 October 2022. During this inspection the provider demonstrated that some improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.
At our last inspection we recommended that the service implemented a plan to check people’s DoLS application statuses at regular intervals. We also recommended the provider made sure all staff were aware of the importance of offering people a choice of meals and they had enough support to enable them to have adequate nutrition and hydration. At this inspection we found the provider had acted on the recommendations and had made improvements.
Why we inspected
We carried out an announced focused inspection of this service on 17 August 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, need for consent, person centred care, safeguarding service users from abuse and improper treatment, premises and equipment, good governance and staffing.
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
At this inspection we found whilst some improvements had been made, further improvements were still required as the provider remained in some breaches of regulations. You can see what action we have asked the provider to take at the end of this full report.
We undertook a focused inspection to review the key questions of safe, effective and well-led only.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from inadequate to requires improvement based on the findings of this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Windsor Care Centre on our website at www.cqc.org.uk.
Enforcement
We have identified breaches in relation to fire risk management, medicines management and quality assurance systems at this inspection. Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.