24 March 2021
During an inspection looking at part of the service
Windsor Court is a residential care home providing personal and nursing care to 48 people aged 65 and over at the time of the inspection. The service can support up to 77 people. The service is split into four units across two floors.
People’s experience of using this service and what we found
Systems in place to monitor and improve the quality of the service had not always been effective. Areas identified at this inspection had not been addressed. Improvements were required to ensure effective communication with people’s relatives and staff.
There was not always enough staff to meet people’s needs. Systems in place to assess the staffing levels and rota staff on shift were not always accurate.
The environment was not suitably maintained, for example attention was required to some flooring and carpets.
Records were not always fully detailed or accurate. This included medication records, care plans and risk assessments.
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.
A new senior management team was supporting the service. They were in the process of auditing the service and making improvements but required further time for these to be embedded and sustained.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last inspection was a targeted inspection therefore the service did not receive a rating (published 18 March 2020). This meant the provider kept the rating of good from the previous inspection published 20 November 2018.
Why we inspected
We received concerns in relation to infection control and from our internal monitoring systems. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.
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.
The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvement. Please see the safe and well-led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Windsor Court on our website at www.cqc.org.uk.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified breaches in relation to the maintenance of the building, staffing levels and systems to monitor and improve the quality of the service 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 for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.