CQC report explained · a residential care home
What the CQC found at Windward House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, August 2019
Rated Good overall; inspectors found kind, safe care, but the home's leadership and record-checking needed improvement.
This was an unannounced inspection on 23 and 25 July 2019. One inspector and an Expert by Experience spoke with 11 people, one relative and six staff. They reviewed six care records, medicines, recruitment, training and quality checks.
People told inspectors they felt safe and happy. Staff were kind and respectful. There were enough staff, medicines were managed safely, the home was clean, and people's care, food, activities and communication were generally tailored to their needs.
The main weakness was how the home checked the quality of its own work. Some risk records, DoLS records and staff supervision records were incomplete or not up to date. The home was rated Requires Improvement for well-led, although the other four areas were rated Good.
The overall rating was Good. This was unchanged from the previous inspection, but the well-led rating had fallen from Good to Requires Improvement. CQC made recommendations for improvement, but the report does not say that regulations were breached.
Kind and respectful care
People described staff as kind, and inspectors observed friendly, respectful and attentive care. Staff supported people's dignity, privacy, choices and independence.
“People told us staff understood the importance of treating people with dignity and compassion.” from the report
People felt safe
People said they felt safe, and staff knew how to recognise and report abuse. The home had safe recruitment processes and enough staff to meet people's needs.
“There were enough staff available to support and meet people's assessed needs, staff were not rushed and had time to spend with people.” from the report
Safe medicines management
Medicines were stored, recorded and given safely. Staff were trained and their competence was checked regularly.
“People's medicines continued to be stored, recorded and administered safely.” from the report
Personalised support
Care plans included people's needs, preferences and communication methods. People could choose activities, food and how they spent their time.
“People continued to receive person-centred care. Care plans were detailed and personalised.” from the report
Clean and maintained home
The home was clean and well maintained. Equipment, fire safety systems and infection control arrangements were checked.
“Windward House was clean, tidy and fresh smelling.” from the report
Quality checks missed incomplete records
needs fixingThe home's governance checks did not reliably identify records that were incomplete, inaccurate or out of date. This affected risk information, DoLS records and staff supervision records.
“However, we found the systems in place had not been undertaken robustly and therefore had not identified that some records were not accurate, complete or up to date.” from the report
Some risk plans lacked detail
needs fixingFour people's records did not clearly explain what staff should do to manage risks linked to smoking and lifestyle choices. The report says there was no negative impact on people's safety, and the provider later confirmed guidance was in place.
“For example, we found four people's care records lacked detail of the action staff had taken to manage risks associated with people's life style choices (smoking).” from the report
DoLS paperwork was incomplete
needs fixingTwo people on respite stays were subject to restrictions, but the required DoLS applications had not been made at the time of inspection. The manager said action would be taken, and inspectors found no disadvantage to these people.
“Records showed staff had not applied for the required DoLS at the time of the inspection.” from the report
Staff supervision records
needs fixingThe records reviewed did not show that four staff had received regular supervision as required by the provider's policy. The manager said the recording system would be reviewed.
“None of these staff files contained sufficient evidence to demonstrate staff were receiving regular supervision in line with the providers policy and expectations.” from the report
- 01What has the home changed to make sure care records clearly explain how each known risk, including smoking-related risks, will be managed?
- 02What is the current process for identifying people who may need a DoLS application, particularly during respite stays?
- 03How are staff supervision meetings now recorded, and how does the home check that they happen regularly?
- 04How does the management team test whether its quality assurance checks are finding incomplete or outdated records?
- 05What progress has been made since the well-led rating fell from Good to Requires Improvement?
This was an unannounced planned inspection covering all five key questions, including the premises and care provided; the overall rating remained Good, while well-led fell to Requires Improvement. This explanation was written from the published report of 30 August 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.
What inspectors found, March 2017
Windward House was rated Good; inspectors found safe, kind and personalised care, with significant improvements since 2015.
The inspection was unannounced and took place on 24 January 2017. The inspector spoke with people living in the home, relatives, staff and managers. They observed care and reviewed medicines, meals, care plans, risk assessments, staff files and other records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People were protected from risks, received their medicines as prescribed and had enough staff to meet their needs. Staff understood people's health needs and supported their choices, food preferences and access to healthcare.
Inspectors found kind and respectful care. Care plans contained personal information and were used to plan activities that suited people's interests. The report says action had been taken after the previous inspection in 2015, including improvements to risk management, medicines, the environment, people's rights, activities and record keeping.
Safe care
Risks relating to health, mobility, eating, drinking, medicines and behaviour were assessed and managed. Staff also reviewed accidents and incidents.
“People were protected from risks relating to their health, mobility, medicines, nutrition and behaviours.” from the report
Kind and respectful staff
Inspectors saw positive interactions. Staff knew people's preferences and supported privacy, dignity and independence.
“Staff treated people with kindness and respect. People's privacy and dignity were respected.” from the report
Personalised care
Care plans included people's histories, interests and preferences. This information was used to plan individual activities and support.
“People's care plans contained detailed information about people's histories, their individual needs, preferences and interests.” from the report
Activities and stimulation
People had more opportunities for activities inside the home, in the community and on trips. Activities reflected individual interests and choices.
“People had access to a range of activities which met their social care needs.” from the report
Improved management
The home had strengthened its audits, feedback systems and records. Inspectors found records were clear, organised and up to date.
“During our inspection we found records were clear, well organised and up to date.” from the report
Authorisation of restrictions
needs fixingThe manager had made the appropriate applications for people whose liberty was being restricted, but all were still awaiting authorisation when inspectors visited.
“The registered manager had made the appropriate DoLS applications to the local authority. All of these were still awaiting authorisation.” from the report
Previous complaint
minorA complaint about an incident and how it was handled had been upheld by the ombudsman before this inspection. The manager said the home had learned from it and improved its processes.
“The ombudsman had found in favour of the complainant.” from the report
- 01Have all the outstanding Deprivation of Liberty Safeguards applications now been authorised?
- 02What changes were made after the complaint that the ombudsman found in favour of the complainant?
- 03How are medicines audits and recording checked now?
- 04How will you create an activities plan based on my relative's interests and history?
- 05How will you involve my relative and our family in care plan reviews and decisions?
This was an unannounced inspection of the overall service, covering all five key questions; the report says previous concerns from October 2015 had been addressed. This explanation was written from the published report of 16 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 Windward House
3 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- August 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2014
Report published without a new overall rating.
- May 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 31 January 2011.
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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