Windsor House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We inspected 6 quality statements under the Safe domain. We found breaches of regulations. The providers processes did not ensure people were protected from abuse. Staff were not always aware of how to report abuse, and safeguarding incidents had not been reported appropriately. Safety risks to people were not managed well. Staff had not received appropriate training or clear written guidance on how to support people safely. The service was not appropriately maintained, and environmental risks were not effectively managed. Medicines were not managed safely, and we were not assured that people received their medicines as prescribed.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People experienced the risk of harm because they were not protected from abuse. People had not always been safeguarded from risks of avoidable harm and there were multiple safeguarding investigations which were ongoing at the time of our inspection. Accidents and incidents were not consistently recorded, and appropriate action was not always taken in response to incidents.

Staff were not able to demonstrate they had a good understanding of their responsibilities under safeguarding and how to keep people safe. Staff spoken with were not able to tell us what they would do if they became aware of a safeguarding concern. Staff told us that their training had been online but were not able to explain what actions they would take if they became aware of abuse other than to report to a senior. Senior staff and managers did not always recognise when incidents constituted a safeguarding concern.

Whilst we did not observe any abuse while at the service, we could not be assured people were protected from the risk of abuse based on the risk identified during this inspection and the provider and staff failure to recognise risk to people present in the environment.

The provider’s systems, processes, and practices to protect people from abuse were not effective. The incident folder did not contain a record of all the incidents which had occurred. Incidents that occurred between 2 May 2024 and 7 October 2024 were not recorded. At the time of the assessment, we were aware of incidents including a person developing a pressure ulcer and another person falling from bed which should have been recorded. This meant that the service did not record the information necessary to identify potential abuse in order to take preventative action, including escalation if appropriate.

People were unable to answer questions about risk. However, records kept by staff and our observations demonstrated to us that risks to people living in the service were not being effectively managed. There was a lack of up-to-date risk assessments and risks present in the environment had not been considered and appropriate mitigating steps taken to protect people from harm.

Staff told us that 4 people, who had complex care needs including dementia, did not have care plans in place. They told us that they found out from other members of staff what people’s care and support needs were. When asked how they knew about people’s care and support needs and how to support them safely a member of staff told us, “Only way we know is what they [people] tell us.” This was not an effective process for sharing crucial information between staff.

We observed a person using the stairs from the first floor to the ground floor. They appeared unsteady on their feet and at risk of falling. The provider’s representative confirmed that this person did not have a risk assessment in place relevant to their use of the stairs. Therefore, potential risks to this person’s safety had not been considered. We also found the heating was not working efficiently on the top floor of the service, and at times not working at all. Small portable oil filled radiators were being used instead. The safety of these and any potential risks to people, such as burns, had not been considered or assessed.

People were not protected from the risk of potential harm and unsafe care because not all their care needs had been assessed. 3 people did not have any care records and a fourth person, who had lived at the service for many months, had only the basics of a care plan recently written. For the 3 people, other records we reviewed did not contain risk assessments for the relevant areas of care such as poor skin integrity. For example, 1 person with multiple support needs did not have a care plan in place. This person needed 2 members of staff to support them with moving and repositioning, the use of a hoist to transfer, was prescribed inhalers, was pre-diabetic and had experienced weight loss. They had fallen out of bed at least once. Despite their extensive support needs there were no risk assessments in place to identify risk associated with their care and support needs and inform staff how to deliver care safely.

People did not live in a safely maintained environment. Their furniture was tatty and damaged, carpets were worn and their towels were threadbare.

Whilst the providers representative told us they were working on improving the furnishings in the service they had failed to address the concerns, act on them in a timely manner and ensure appropriate solutions. They told us that they had provided cabinets for storing personal protective equipment as required in a recent infection control inspection. However, we found these cabinets were not fit for purpose, having porous surfaces, which were an infection risk.

The environment was tired and shabby in places and did not always reflect people’s preferences or needs, including support for people living with dementia to remain as independent as possible. The safety of the building was not maintained to ensure people’s safety placing people at risk of harm. Our observations found that potential risks in the environment had not been identified or addressed. For example, risks associated with access to the main stairs had not been considered, which meant people at risk of falls were able to freely access them. Their safety to do so not assessed. Personal care and medical items were stored in people’s bedrooms with no risk assessment. We found an exposed pipe which was too hot to touch and placed people at risk of serious burns should they have fallen or been too near it. Following us raising it, the hot pipe was addressed by the service maintenance person on the first day of our inspection visit. On the second of our inspection visits we saw workmen had left tools obstructing corridors and propping fire doors open. There was no risk assessment in place to ensure work was carried out safely. We also identified razor blades contained within unlocked communal cupboards.

We reviewed the systems and processes in place relating to the management and oversight of environmental risk and safety. Processes in place had not ensured the environment was safe. No fire drills were taking place and other routine maintenance tasks to ensure the risk of fire was well managed had not been completed. For example, a fire risk assessment carried out on 29 October 2024 identified significant concerns, including environmental defects which the processes had failed to identify. These included out of date electrical wiring tests, no evidence of the gas boiler being serviced, and no evidence of the sprinkler system being serviced. Following our inspection, we were also made aware that there was legionella in the water system at the service - insufficient action had been taken in response to this which placed people, staff and visitors at significant risk of harm.

People were not always supported by staff in a timely manner. One person described to us how their bed was always very wet in the mornings and when they rang their bell for support staff did not come to support them. This person also told us that the trousers they were wearing were uncomfortable. Staff were made aware of this. We checked back with the person after approximately 2 hours and found the person had not received any support to make them more comfortable.

Care staff told us that their induction had been 2 days shadowing and 3 days on site. When asked what the induction consisted of a member of staff told us, “Other staff taught me how to use the hoist and do personal care. I was shown how to use the hoist with a resident.” Another member of staff told us they had been interviewed online, had online training and their training had consisted of shadowing other staff. They were unclear of what was expected of them on shadowing and induction days and what the difference was, if any. Care staff were not equipped to provide care in a safe, comfortable and dignified manner in accordance with best practice. Four staff spoken with confirmed they had not received any group or 1:1 supervision and that staff meetings did not take place. Staff supervision gives staff and their line manager the opportunity to review their work, look at any skills gaps and development needs and put action plans in place to address them. Care staff were not equipped to provide care in a safe, comfortable and dignified manner in accordance with best practice.

Due to English not being their first language, some members of care staff they were unable to understand what we were asking when speaking with them. We re-phrased the questions several times, but they were still unable to understand. The inability to communicate effectively meant staff may not be able to engage with people when providing care and support. It also meant that should an emergency occur staff would be unable to communicate with emergency services.

Training provided did not ensure staff had the necessary skills to provide effective support. There were no processes in place to ensure staff were skilled and competent in their role. For example, staff handling people’s medicines had not recently had their competence assessed.

People were unable to answer questions asked about infection control. However, we observed people lived in an environment where infection control was not managed effectively.

Not all staff employed had a good understanding of infection prevention and control which was demonstrated by their actions.

A health professional infection prevention and control audit completed on 26 September 2024 had identified areas of concern. These included commodes not effectively cleaned, and damaged mattress covers. During our inspection visit on 31 October 2024 we found these issues had not been addressed. We observed unclean commodes and split mattress covers. We observed that when staff gave people their medicines, they did not always follow safe hygiene procedures.

There were insufficient systems and processes in place to ensure people, visitors and those employed within the service were fully protected against infection control risks. There were no provider infection control audits completed that would identify any areas of risk or staff practice that could be improved to mitigate potential risk. Shortfalls in infection prevention and control identified by external stakeholders and through the assessment were not reflected within the provider’s own systems.

People were not supported to receive their medicines in a safe way. There were a high number of medicines errors, and staff could not always be sure if people had received their medicines correctly or not and as the prescriber intended. We found that staff lacked knowledge about medicines and observed that when staff gave people their medicines, they did not follow safe hygiene procedures. All of these concerns affected people’s experience.

Staff handling people’s medicines lacked knowledge about medicines and had not recently had their competence assessed. This meant their practice had not been assessed to ensure they had the skills to administer people’s medicines.

Refrigerated medicines were not being kept securely. In addition, people’s topical medicines were not being kept securely in their rooms putting them at risk of people accessing them and causing themselves accidental harm. There were numerical discrepancies and gaps in medicine administration records which therefore did not confirm that people always received their medicines correctly and as intended by prescribers. This included short courses of antibiotics. We noted that medicine administration records were not always accurately updated following changes to medicines and were sometimes not clearly written to ensure safety. We found there to be a lack of supporting information available for staff to refer to when giving people their medicines. This included written information about how to give people their medicines, people’s identification and medicine allergies. When people were prescribed medicines on a when required basis (PRN), there was a lack of detailed written guidance for staff to refer to ensure they were given consistently and appropriately. We noted that staff did not always handle containers of medicines in a way that ensured they were only used within their shelf-life. The service had not considered and recorded the risks around people’s medicines. Regular checks of medicines were not being conducted. In addition, errors and incidents related to people’s medicines were not being recorded with any actions taken and processes were not in place to ensure staff learnt from them.