Windsor House

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We inspected 6 quality statements. We found breaches of regulations. People’s needs and rights were not supported. People’s care and treatment were not effective due to their health, care, well-being, and communication needs not being assessed with them or relatives to ensure staff were provided with clear information and guidance. Some people did not have care plans, other care plans were not up to date and assessments had not been completed in a timely manner. Staff were not provided with clear guidance on people’s preferences to enable them to support in a person-centred way. People were not aware of their rights around care and treatment.

This service scored 33 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

A lack of pre-assessment processes and effective care planning had a negative impact on people. The lack of care plans for 4 people demonstrated that people’s care needs had not been assessed.

Staff told us that 4 people did not have care plans. They also told us that where people had care plans in place they had not read these. Staff told us that they found out how people should be supported by speaking and observing other care staff. The provider’s representative told us that some care plans were kept on an electronic system. However, they were unable to access this during our inspection visits and the electronic care plans were not available to care staff.

Processes for assessing people’s needs were not effective. As well as there being 4 people who did not have care plans, where care plans were in place these had not been consistently updated, some for at least 2 years. For example, 3 people had skin integrity concerns or were at risk of pressure ulcers. None of these people had up to date assessment using a recognised assessment tool such as the Waterlow Score which is used to identify people who may be at risk of developing a pressure ulcer .

There was no evidence that people’s experience included involvement in their care planning. The lack of care plans for some people and out of date assessments and care plans for others demonstrated that people had not been involved in their care planning.

Staff were unable to tell us how they met people’s individual care needs. Staff told us they had not read the care plans but instead relied on daily notes and other staff to ensure they were meeting people’s needs.

Peoples care and support was not planned with them. For example, 4 people did not have care plans in place. Two of these people had moved into the service in July 2023 and 2 in April 2024 due to their vulnerability and health support needs. The care records which were available did not include all the required information in a consistent format to ensure people's changing needs were appropriately responded to. For example, a person had lost 13.8% of their body weight in the last 6 months. Food monitoring charts in place did not evidence the person had been offered additional snacks and fortified foods. Lack of formal staff training did not equip staff to provide care in line with up-to-date good practice. For example, staff spoken with confirmed they had not received practical moving and handling training.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

People’s experience and support to live a healthy life was not positive. There was limited evidence to suggest people were supported to have healthy lives, frequent and regular snacks for people at risk of weight loss were not evident. There were limited activities for people to promote wellbeing, therefore people were often bored and unstimulated.

Staff spoken with told us they were unable to access people’s care plans and that some people did not have care plans. This meant that they did not know people’s individual health needs and were therefore unable to support them to remain healthy or improve their health.

Records did not demonstrate that people were supported to live healthier lives. For example, 11 people had lost weight in the past 6 months. Where care plans were in place these did not demonstrate this had been explored or that appropriate timely referrals had been made to health care professionals.

People did not always experience good outcomes. We are aware of a person who on transferring to another service was found to have an infection, deep tissue injuries and a pressure ulcer that had not been identified at Windsor House and therefore no plan of active care was in place for these wounds.

The staff team had not identified the significant shortfalls we had identified during our visits. In addition, they had not identified shortfalls and concerns noted by the local authority.

Processes did not support people to experience good outcomes. For example, in the case referred to above there was no care plan in place. The person’s skin integrity had not been reviewed since 13 December 2022 and did not include the risks to the person’s skin integrity and the support required for them to reduce the risks to their wellbeing and safety.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. During our visits, we saw whilst some staff asked for people’s consent before providing any support, some staff did not and were task focussed. We also had wider concerns about how people were supported and how their rights under the MCA were respected.

Staff and leaders did not ensure consistent compliance with the MCA. People’s capacity had not been considered and recorded in all areas of their care.

We were not assured that capacity assessments and best interest decisions were in place for people who lacked capacity to make a decision. People’s consent to care was not always recorded, in particular for people who lacked capacity to make decisions about their care and health.