Windsor Court Care Home

Windsor Court is a care home providing personal and nursing care for up to 44 people. The home was divided into 3 Suites: Elizabeth Suite on the ground floor for mixed occupancy, Mountbatten Suite on the second floor for men, and Bowes Lyon Suite on the top floor which was for women.

At the time of our inspection there were 39 older people living at the service, including those who were living with a dementia and 2 people who had a learning disability. The home was not registered as a specialist service for people with autism or a learning disability. Because there were 2 people living at the home who had a learning disability, we assessed the service against the ‘Right Support, Right Care, Right Culture’ guidance to judge whether the provider ensured people with a learning disability and autistic people were treated with respect, equality, dignity, and had choices, independence, and good access to local communities that most people take for granted. The registered manager was not aware of this guidance and therefore had not mapped the service against these standards. In addition, the statement of purpose had not been updated to reflect these principles, and we found shortfalls in how the guidance was applied within the service.

We carried out the assessment because we had received concerns about people’s care, staff conduct and the management of the service. The home was in organisational safeguarding. This meant the local authority was monitoring the service and supporting them to ensure the correct procedures were in place to keep people safe.

We found 2 breaches of the legal regulations relating to safety and governance.

Systems to safeguard people and manage risks were not fully effective. We identified shortfalls in relation to medicines management, the provision of equipment, infection prevention and control, and environmental safety.

Leadership and governance arrangements were not robust. Oversight of risk, incidents and complaints was inconsistent, and systems to monitor and improve quality were not always effective. Staff did not always feel confident to speak up, and they told us they would appreciate the registered manager being more visible around the home.

An effective system was not fully in place to ensure there were sufficient, suitably skilled and supported staff deployed. Staffing levels, gender and skill mix did not always meet people’s needs. We also identified shortfalls in staff practices in relation to areas such as medicines management, compliance with the Mental Capacity Act, record keeping, and restrictive practices.

Care planning and delivery were not consistently person-centred or based on best practice. Information relating to people’s care and support was not always accurate or in place in relation to mental capacity, nutrition and fluids and meeting people’s social needs.

While the registered manager had introduced an action plan and improvements were underway, further work was required to ensure sustained progress and a positive culture across the service.

Despite these issues, we saw positive staff interactions. We heard and observed examples of how living at the home had improved people’s health and wellbeing. The provider was working with external agencies to address identified issues, and there was evidence of a commitment to improvement.

We have asked the provider for an action plan in response to the concerns found at this assessment.