CQC report explained · a residential care home
What the CQC found at Windermere Rest Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found improvements in infection control, risk assessments, lifting equipment checks and medicines management. Staff recruitment and safeguarding systems were also considered safe.
- Effective?
- Good
- This question was not rated in this inspection.
- Caring?
- Good
- This question was not rated in this inspection, although people spoke positively about the staff and support they received.
- Responsive?
- Good
- This question was not rated in this inspection, although care records were described as person-centred and staff knew people's individual needs.
- Well-led?
- Requires improvement
- The manager had introduced audits and acted on improvement plans, but had not registered with the CQC. This rating remained Requires Improvement.
What inspectors found, July 2021
Windermere Rest Home was rated Good overall; inspectors found safe, kind care and improvements, but management was not always well-led.
This was an unannounced inspection on 29 June 2021. One inspector spoke with all five people living there and three staff. Records about care, medicines, recruitment, training and management were also checked.
The home was rated Good for Safe. Inspectors found better infection control, clear risk assessments, safe medicines systems, suitable staff checks and regular equipment maintenance. People said they felt safe and were happy with the staff.
Well-led was rated Requires Improvement. The manager had introduced audits and made improvements, but had not registered with the CQC. The overall rating improved from Requires Improvement at the previous inspection, and the home was no longer in breach of regulations.
Improved infection control
Cleaning schedules, enhanced cleaning, safe use of protective equipment and visitor arrangements were in place. The environment had also been changed to support infection control.
“Staff were using PPE (personal protection equipment) effectively and safely.” from the report
Safer risk management
People's risk assessments and care plans had improved. Instructions for using hoists were clear, and lifting equipment was checked regularly.
“Risks were clearly documented and mitigated against in peoples support plans.” from the report
Safe medicines systems
Medicines were stored, ordered, given, monitored and disposed of through suitable systems. Records checked by inspectors were in good order.
“Medicine records we reviewed were in good order.” from the report
Kind and personal care
People were positive about staff. Staff knew how to support individuals, including when someone was distressed.
“Staff new people well and how best to support them.” from the report
Improvements since the previous inspection
The provider had acted on an independent audit and made changes including new flooring, beds and a hoist.
“We saw they had put an action plan together from the audit and had acted on the findings.” from the report
Manager not registered with the CQC
needs fixingThe manager had been in post since 2019 but had not registered with the CQC. The manager said they would apply, but this was still unresolved when inspectors visited.
“Since then a new manager has been in post however, they have not registered with the CQC.” from the report
- 01Has the manager now applied for and obtained registration with the CQC?
- 02What improvements have been made since the inspection to address the Requires Improvement well-led rating?
- 03How often are audits of care, medicines, infection control and the environment completed, and what happens when they identify a problem?
- 04How are risk assessments and care plans updated when a person's needs change?
- 05How are people and relatives asked for feedback, and how is that feedback acted on?
This inspection rated Safe and Well-led only; Effective, Caring and Responsive were not rated in this report. This explanation was written from the published report of 29 July 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, May 2019
Windermere Rest Home was rated Requires Improvement; inspectors found kind care but gaps in infection control, lifting equipment checks and management oversight.
This was an unannounced planned inspection on 15 April 2019. One inspector spoke with six people, the manager and two care workers, observed care and checked care, recruitment and service records.
People generally described kind and respectful staff. Inspectors found safe recruitment, suitable staff training, safe medicines management, good support with food and healthcare, and regular care plan reviews.
There were important shortfalls. Cleaning was not always adequate, some lifting equipment checks were late or poorly recorded, and one hoist care plan lacked essential instructions. The systems used to check and improve the home were not strong enough.
The overall rating was Requires Improvement. Safe and Well-led were rated Requires Improvement, while Effective, Caring and Responsive were rated Good. The previous rating was Good, published on 4 October 2016.
Kind and respectful staff
People were treated with empathy, dignity and respect. Staff supported people to make choices and remain as independent as possible.
“Staff cared for people in an empathetic and kind manner.” from the report
Training and recruitment
The home completed the required recruitment checks. New staff received an induction and staff had training, supervision and appraisals.
“New staff to the service had a full induction including three to five days shadowing more experienced staff.” from the report
Food and healthcare
People said they had enough food and drink, with choices and support for dietary needs. Staff arranged medical and other healthcare appointments when required.
“Staff catered for people's likes and dislikes and specific dietary requirements.” from the report
Personalised care
Assessments included people's preferences and communication needs. Care plans were reviewed regularly, and people and relatives were involved.
“Full assessments and care plans were completed and reviewed every month to update them” from the report
Kind care
People said they felt happy and had good relationships with staff, who offered reassurance when people were anxious.
“Staff and people had good relationships and people were relaxed in the company of staff holding conversations with them.” from the report
Infection control and cleanliness
seriousInspectors found visible dirt, including a door frame that appeared to have faecal matter on it. Cleaning schedules did not include deep cleaning, and one bedroom had a strong urine odour.
“There were not robust infection control procedures in place.” from the report
Lifting equipment and care instructions
seriousSome equipment used to lift people had not been examined for eight months, and records did not clearly show what had been checked. One care plan did not explain the hoist and sling arrangements clearly enough.
“We found a gap in the services records that some equipment had not been tested or examined for eight months.” from the report
Weak management checks
seriousAudits and other monitoring systems had not identified or resolved several problems, including equipment checks, the hoist care plan and cleaning issues.
“The registered manager needed to implement better systems to give them a clearer understanding and oversight of the service.” from the report
Limited activities
needs fixingInspectors found limited activities for most people. They recommended matching activities more closely to people's needs, including offering one-to-one activities where appropriate.
“We saw there was limited activities provided for most people at the service.” from the report
Medicines follow-up
needs fixingMedicines were given safely, but PRN instructions were not kept with the medicines charts and actions identified in audits had not all been completed.
“PRN protocols were kept in people's care records, and not easily accessible for staff to refer to.” from the report
- 01What action have you taken to improve infection control, including the deep cleaning of rooms and the cleanliness issues found by inspectors?
- 02Are all lifting devices and accessories now examined every six months, and can you show us the latest records?
- 03How do care plans now record the correct hoist, sling and loop instructions for each person who needs them?
- 04How do you check that audit recommendations, including medicines and kitchen hygiene actions, are completed?
- 05What activities are now available, including one-to-one activities for people who need them?
This was a planned inspection of all five CQC questions, based on the previous rating; the report does not say that any question was excluded. This explanation was written from the published report of 9 May 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Windermere Rest Home
4 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- July 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- October 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2013
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 3 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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