CQC report explained · a nursing home
What the CQC found at Windsor Care Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2023
Windsor Care Centre is rated Requires Improvement; inspectors found important safety and record-keeping problems, although significant improvements mean it is no longer in special measures.
This was an unannounced focused inspection on 6 July 2023. Inspectors reviewed the Safe, Effective and Well-led areas. They spoke with people, a relative and staff, observed care, checked care and medicines records, and reviewed training, recruitment, complaints and audits.
The home had improved staffing, training, infection control, food choices and communication. People said they felt safe and that staff responded quickly. However, medicines were not always managed safely, fire risks were not always followed up, and pressure mattress settings were not checked properly.
The home remained in breach of Regulation 12 for safe care and treatment and Regulation 17 for good governance. Its overall rating improved from Inadequate to Requires Improvement, and it was no longer in special measures. Effective remained Requires Improvement. Caring and Responsive were not inspected in this visit, so their previous ratings carried over.
Staffing and recruitment
Inspectors saw enough staff on duty and said people received help promptly. Recruitment checks had also improved.
“On the day of the inspection, we saw there were enough staff on duty to meet people's needs.” from the report
Safeguarding
People said they felt safe. Staff knew how to report concerns and safeguarding training was up to date.
“People were supported by staff that knew how to raise safeguarding concerns.” from the report
Food and choice
People were offered meal choices and could change their mind. Staff supported people with food and drinks in a dignified way.
“Throughout the inspection we saw people were supported with nutrition and hydration in a dignified way.” from the report
Improved culture
Communication from the management team had improved. Staff said they felt supported and able to raise concerns.
“Staff felt empowered to speak up and call out poor practice.” from the report
Medicines
seriousSystems did not always ensure medicines continued when people temporarily left the home. Guidance and records for PRN medicines were incomplete, and the legal process for some covert medicines had not been fully followed.
“Where people temporarily left the home, the provider did not have systems in place to ensure the continuity of medicines administration.” from the report
Fire safety
seriousFire drill records did not consistently show who attended, what they did or what action was needed. A faulty emergency lighting issue was recorded without remedial action.
“The provider's auditing systems were not used effectively to manage fire risks and we identified some missed opportunities where learning could have occurred.” from the report
Pressure damage risk
seriousThere was no process to check that pressure mattresses were set correctly. Inspectors found one mattress set at a much higher weight than the person's actual weight.
“There was no process in place to ensure mattress settings were checked and correct.” from the report
Quality checks and records
seriousAudits did not identify all the problems found during the inspection. Some records contained conflicting or incorrect information, including risk assessments.
“Audits of medicines management and care plans were still not fully effective.” from the report
- 01What checks now make sure medicines are continued when a person temporarily leaves the home?
- 02How do you decide when PRN medicines are needed, and how do you record their effect?
- 03What action has been taken on the fire safety recommendations and faulty emergency lighting identified in the report?
- 04How are pressure mattress settings checked and recorded for each person?
- 05How do you check that care plans, risk assessments and medicines audits are complete and accurate?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 28 October 2023 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, October 2022
Rated Inadequate and placed in special measures; inspectors found people at risk from unsafe care, weak management and poor hygiene.
This was an unannounced focused inspection. Inspectors visited on 17 August 2022 and carried out further interviews and checks until 22 August. They spoke with people, relatives and staff, and examined care plans, recruitment files, medicines records, training records and other documents.
Inspectors found serious safety problems. These included poor risk management, unsafe restraint, unexplained injuries that had not been referred to safeguarding, inadequate staffing, medicines storage problems, faulty equipment, fire risks and poor infection control. They also found that staff did not always receive the training needed for their roles.
Care was not always person-centred. Assessments did not consistently record people's dementia, mental health, culture or preferences. Some people were not offered a choice of meals or enough time and support to eat. The service also did not consistently follow the Mental Capacity Act when recording consent.
The overall rating fell from Good at the previous inspection to Inadequate. Safe and well-led were rated Inadequate, while effective was rated Requires Improvement. The service was placed in special measures, meaning CQC said it would monitor the home closely and normally re-inspect within six months.
Positive feedback
Some people, relatives and staff said they felt safe and were positive about the care, support and management they experienced.
“People and relatives said they felt they were safe from abuse.” from the report
Some medicines records
Although medicines management was unsafe overall, inspectors found several useful safeguards in the records.
“Medicines administration records were satisfactorily completed. There were no gaps in the records.” from the report
Emergency information
Emergency plans explained the staffing and equipment each person would need if they had to be evacuated.
“Emergency plans were in people's files in the event of an evacuation, such as a fire.” from the report
Healthcare involvement
A range of healthcare professionals were involved in people's care when needed, including occupational therapists and tissue viability nurses.
“Other healthcare professionals such as podiatrists, tissue viability nurses, occupational therapists and tissue viability nurses were involved in people's care, when required.” from the report
Some supportive mealtimes
On one unit, staff offered choices, waited patiently and encouraged people to eat and drink.
“Observations on another unit showed people were offered a choice of meals and staff waited patiently for them to decide” from the report
Safeguarding failures
seriousUnexplained injuries were not properly investigated or referred, some safeguarding training had expired, and restraint was not always used only when necessary.
“This practice was not in line with the service's safeguarding policy and procedures dated 16 May 2022” from the report
Insufficient staffing and training
seriousThere were not enough staff to supervise people with identified risks. Many staff lacked training in areas such as falls, manual handling, medicines, dementia and food hygiene.
“There were not enough suitably qualified, competent, skilled and experienced staff to make sure peoples' care and support needs.” from the report
Poor infection control
seriousInspectors found dirt, overflowing bins, incorrectly stored protective equipment, unlocked sluice rooms and practices that could spread contamination.
“People were placed at risk of harm from various infections, because hygiene standards were inadequate.” from the report
Weak quality oversight
seriousAudits did not identify the problems found during the inspection. Board oversight had not taken place for 16 months, and there was little evidence that lessons were learned.
“Quality assurances systems in place were ineffective.” from the report
Consent and person-centred care
seriousConsent was not always established lawfully. Care assessments did not consistently record people's individual needs, preferences, culture or life history.
“The registered person failed to ensure consent was correctly established in accordance with the Mental Capacity Act 2005.” from the report
- 01What specific changes have been made to prevent falls and ensure people who need close supervision are not left alone?
- 02How are medicines now stored, and how often are staff checked as competent to administer them?
- 03What specialist training have staff completed for dementia, delirium, mental health, manual handling and complex health conditions?
- 04How do you check that consent, best-interest decisions and DoLS applications are legally up to date?
- 05How have infection control, fire safety, cleaning and faulty equipment been improved and independently checked?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and the overall rating used the previous ratings for the questions not inspected. This explanation was written from the published report of 11 October 2022 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 Windsor Care Centre
3 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- October 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2022Inadequatedown from GoodSafe: InadequateEffective: Requires improvementWell-led: Inadequate
- June 2018GoodSafe: GoodEffective: GoodWell-led: Good
- March 2017
Registered with the Care Quality Commission on 6 March 2017.
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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