Windsor House

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We assessed 7 quality statements in the well-led key question. We found breaches of regulation. There were not effective governance, management and accountability arrangements. The systems to manage current and future performance and risks to the quality of the service did not take a proportionate approach to managing risk that allowed new and innovative ideas to be tested within the service. Information was not used effectively to monitor and improve the quality of care. Staff did not always understand their role and responsibilities. Notifications to the CQC and other agencies were not always made appropriately.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We found serious concerns about people's care, safety and the living environment. The provider, manager and senior leaders showed a lack of understanding of how to respond and safely care for people in a residential environment, as well as a lack of understanding of the relevant regulations. Staff told us there had been changes recently within the management Overall there was a lack of consistent leadership in the service which had impacted the service negatively.

Leadership at the service had failed to ensure there was a positive culture at the service. At the time of assessment there were no team meetings regularly held. There were also no meetings for people and relatives so their feedback and ideas could be sought. Feedback from people, relatives and staff was not being sought to monitor and improve the service and to develop a shared direction.

The service did not have a registered manager and was in the process of recruiting into this role during the inspection. The provider’s representative told us the governance processes had not been followed by the previous manager and this had attributed the failings in the safety and quality of care at the service. However, the inspection identified policies and processes had not be followed for a significant period of time. The provider had failed identify this by ensuring adequate oversight of the service and ensure standards and people’s safety were maintained.

Staff did not always have clear direction due to the lack of effective assessment of risk and care planning for people. The management within the service were not always visible, and the provider failed to have sufficient oversight to ensure the service was safe. Governance frameworks and systems were either not in place, had not been implemented or did not ensure quality oversight.

Staff were not able to describe the whistleblowing procedures and because no 1:1 supervisions or team meetings were being held; staff were not supported to speak up.

People were not actively involved in sharing feedback to allow for improvements. There were no records of any complaints or compliments. Staff members had not received regular supervision for their role. There was no evidence of any lessons learnt following on from accidents and incidents. The processes in place at the service had failed to ensure that staff feedback was used effectively.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Leaders at the service could not evidence what processes were in place to oversee and maintain the quality of the service. Leaders that we spoke to during the inspection told us about new audit systems that would be put in place however these were not in place at the time of the inspection. The issues we identified during this inspection had not been identified by the providers own governance processes. The lack of governance systems in place at the service placed people at risk of harm. There had also been a significant gap in management oversight of the service following the previous registered manager leaving in July 2024.

There was a lack of oversight to protect people from the risk of abuse and your systems and processes to protect people were not followed. For example, we were made aware of an incident where a person was found outside of the service by a member of the public. There was no record of this incident being investigated by the service or being reported to the local authority. The service had also failed to comply with their statutory duty to notify the Care Quality Commission of the incident. There was a lack of audits carried out and systems had failed to identify and address issues at the service including serious concerns with the management of medicines, management of risk and issues with infection prevention and control. The missing care records, quality of people’s care records and care planning overall required significant improvement. The provider had not ensured that safety events were investigated and reported thoroughly, and lessons were learned to continually identify and embed good practices.

People’s feedback was not sought by the service, and their plans of care were either out of date or missing.

The provider’s representative informed us there were a lot of issues to address and that they were aware of the concerns. We found, however, that they did not have a full awareness of the failings and seriousness and were reliant on external stakeholders to create action plans and to direct where improvements were needed.

Due to the level of and nature of concerns, the local authority took steps to support people to leave the service. A variety of healthcare professionals raised serious concerns with us about the standards of care at Windsor House and people’s safety.

Processes in place at the service had failed to ensure that information recorded about people was always up to date, accurate or sufficiently detailed. This meant that when information was shared about people between services the quality of this information could not be guaranteed.

Leaders at the service told us that the service would improve. However, issues identified at our first inspection visit had still not been acted upon by the time of our second visit. For example, residents did not have up to date personal emergency evacuation plans (PEEPs) available by the time of our second visit despite this concern being raised during our first site visit 10 days before.

Due to our serious concerns, we carried out a second site visit and continued to find people were at risk of harm. There had been limited action to address the issues we raised. Despite being aware of these concerns, the provider still failed to implement measures required to keep people. This placed people at an unacceptable risk of harm.