CQC report explained · a nursing home
What the CQC found at Windsor Street Care Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff with the right skills and safer recruitment arrangements. Risks, safeguarding, medicines, infection control and the environment were managed well.
- Effective?
- Good
- People's needs were assessed and reviewed, with access to health professionals and support with nutrition. Staff received training and followed the Mental Capacity Act principles.
- Caring?
- Good
- Staff were observed to be kind, respectful and compassionate. They adapted communication, protected privacy and dignity, and supported people's individual differences and relationships.
- Responsive?
- Good
- Care and activities were personalised to people's needs and preferences. Complaints were investigated, and end-of-life care supported a dignified and comfortable death, although some short-term admission records were less detailed.
- Well-led?
- Good
- Inspectors found strong leadership, clearer staff responsibilities and an open culture. Quality checks identified issues and actions were followed up.
What inspectors found, May 2018
Windsor Street Care Centre was rated Good; inspectors found safe, kind and personalised care, with some short-term care records still needing improvement.
This was an unannounced inspection on 10 and 12 March 2018. Inspectors spoke with people, relatives, staff and a visiting health professional. They visited all five households and checked care records, medicines, staffing, training, complaints and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough suitably recruited staff, safe medicines, clean surroundings and good support for people's health, food and drink.
Care was described as kind, respectful and tailored to people's needs. People were supported with activities, communication, family involvement and end-of-life care. Leadership and record keeping had improved since the previous inspection, when the home was rated Requires Improvement overall.
There was still a shortfall in records for people using the short-term safe haven beds. These records did not always fully show the care and treatment provided. The manager said an additional daily care record had been added after the inspection.
Improved staffing
Staffing numbers and recruitment had improved since the previous inspection. Inspectors found enough staff to meet people's individual needs and less reliance on agency staff.
“Overall staffing numbers had increased.” from the report
Kind and respectful care
Staff formed caring relationships and adapted how they communicated with people living with dementia. People's privacy, dignity, beliefs and differences were respected.
“We observed kind and caring actions by staff and overheard some genuinely warm conversations between staff and people.” from the report
Personalised activities
People were offered activities based on their interests, abilities and preferences. These included exercise, singing, social groups, individual chats and community activities.
“People were supported to take part in activities, which they enjoyed and which helped them to feel included.” from the report
Improved leadership
Managers had strengthened the staff structure, communication and quality checks. Inspectors found a clear focus on improving people's wellbeing and quality of life.
“The home benefited from strong leadership.” from the report
End-of-life support
People nearing the end of life were supported to remain comfortable and dignified. Relatives could visit freely and could stay overnight where arrangements allowed.
“People were supported to have a dignified and comfortable death.” from the report
Short-term care records
needs fixingRecords for people using the safe haven beds were less detailed and did not always fully record the care and treatment provided. The manager added a daily care record after the inspection.
“Care records for people admitted into 'safe haven' beds were less detailed and not overly personalised.” from the report
- 01How do you now make sure safe haven care records fully record each person's care and treatment?
- 02How are staffing levels adjusted when people's needs change, or when staff are absent?
- 03How will you learn about my relative's communication needs, preferences, routines and personal history?
- 04How will you monitor my relative's food, drink, weight and any risk of choking or poor nutrition?
- 05How are families involved in care reviews, complaints and end-of-life decisions?
This was an unannounced inspection covering all five CQC questions and the overall quality of the home. This explanation was written from the published report of 16 May 2018 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, March 2017
Rated Requires Improvement; inspectors found kind care, but staffing pressures and inaccurate records could put people at risk.
This was an unannounced inspection on 1 and 2 December 2016. One inspector and an expert by experience spoke with people, relatives, staff and health professionals. They reviewed care records, staff files, training records, safety checks, audits and the improvement plan.
The home was clean overall and people received medicines safely. Staff supported people's health, nutrition, dignity and day-to-day choices. People and relatives generally described the care as kind and compassionate. There were activities and arrangements for complaints.
However, some nursing care records were not accurate or up to date. This included records about medicines, wounds and other treatment. The home also faced difficulties recruiting and retaining nurses, and staff on one unit said they sometimes struggled to meet people's needs.
The overall rating was Requires Improvement. Effective and Caring were rated Good. Safe, Responsive and Well-led were rated Requires Improvement. The report says the provider had to act on the record-keeping breach and that CQC would check the action taken.
Kind and respectful care
People and relatives generally said staff were kind, compassionate and respectful. Inspectors observed patient care that maintained dignity and privacy.
“People received care provided in a caring and compassionate way.” from the report
Health support
People had regular access to medical care and specialist professionals. Staff worked with professionals to support people's varied health needs.
“The staff and people's care records confirmed the care home liaised with and worked closely with many other external health care professionals.” from the report
Safe medicines practice
Inspectors found that medicines were given safely and as prescribed, with regular reviews by GPs.
“People received their medicines safely and records relating to medicines were maintained accurately.” from the report
Meaningful activities
The home offered group and one-to-one activities based on people's interests, abilities and preferences.
“Activities and social opportunities were therefore provided in a way that was meaningful to the individual.” from the report
Inaccurate care records
seriousSome records did not reflect changes to medicines, wounds or other treatment. Inspectors said this could result in unsafe or inappropriate care. This was a breach of Regulation 17.
“Poorly maintained and inaccurate care records potentially put people at risk of receiving unsafe and inappropriate care and treatment.” from the report
Nursing staffing pressures
needs fixingThe home was using agency staff and recruiting new staff, but staff reported that one unit was sometimes short of staff. The report recommended a review of staffing levels.
“We recommend that the provider seek advice from an appropriate source and review staffing levels to ensure people's nursing needs are consistently met in a timley and safe way.” from the report
Staff concerns not always heard
needs fixingSome staff said they did not feel able to raise concerns about staffing and dependency levels, and that previous concerns had not led to change.
“Not all staff spoken with told us they had felt able to communicate and give feedback.” from the report
Some cleaning shortfalls
minorThe home was generally clean, but inspectors found debris remaining on some bedroom floors and in one communal room during repeated visits.
“Some bedrooms and one communal room in particular, continued to have debris on the floor at each visit.” from the report
- 01How do you make sure care records are updated immediately when medicines, wounds or other treatment change?
- 02What staffing levels are planned for the nursing unit where my relative would live, and how often are agency nurses used?
- 03How do staff raise concerns about staffing or people's changing needs, and what happens after they do?
- 04What action has been taken to improve care-record audits since this inspection?
- 05How do you make sure people can take part in activities or go out when staff are busy with essential care?
This was an unannounced inspection covering all five areas of the service: Safe, Effective, Caring, Responsive and Well-led. This explanation was written from the published report of 24 March 2017 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 Street Care Centre
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- May 2018Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2017Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2014
Report published without a new overall rating.
- June 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- May 2013
Registered with the Care Quality Commission on 15 May 2013.
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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