Archived: Windsor House

Updated 14 November 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This was a comprehensive inspection that took place on 27 September 2017; the inspection was unannounced. The inspection was carried out an adult social care inspector and an expert-by-experience. An expert-by experience is a person who has personal experience of using or caring for someone who uses this type of care service

Before this inspection we reviewed the information we held about the home, such as notifications we had received from the provider. Notifications are documents that the provider submits to the Care Quality Commission (CQC) to inform us of important events that happen in the service. The provider was asked to submit a provider information return (PIR) before this inspection. The PIR is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. The PIR was submitted within the required timescale.

On the day of the inspection we spoke with seven people who lived at the home, seven relatives, four members of staff, the manager and the nominated individual. We also used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

Following the day of the inspection we received feedback from four social care professionals.

We looked around communal areas of the home and some bedrooms, with people’s permission. We also spent time looking at records, which included the care records for three people who lived at the home, the personnel records for two members of staff and other records relating to the management of the home, such as quality assurance, staff training, health and safety and medication.

Updated 14 November 2017

Windsor House is a care home that accommodates up to 31 older people, some of whom may be living with dementia. On the day of the inspection there were 26 people living at the home. The home is situated in Acomb, on the outskirts of the city of York. Bedrooms are located on the ground and first floors and there is a passenger lift to reach the first floor.

At the last inspection in July 2016 we were concerned that risks had not been managed safely, including the risks associated with medicines and the frequency of fire alarm tests and fire drills. We issued a requirement in respect of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we saw that medicines were managed safely. Risks had been assessed and fire alarm tests and fire drills were taking place. The provider was no longer in breach of this regulation.

At the last inspection in July 2016 we were concerned that staffing levels did not allow staff time to engage people in meaningful activities and that staff could not always respond to people’s needs promptly. We issued a requirement in respect of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we saw that staffing levels were sufficient to meet people’s individual needs and that people received prompt attention from staff. The provider was no longer in breach of this regulation.

At the last inspection in July 2016 we were concerned that there was a lack of consistent evidence that people’s capacity to make informed choices had been considered when seeking consent. We issued a requirement in respect of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we saw that records evidenced people’s capacity to consent had been assessed and people were supported with decision making. The provider was no longer in breach of this regulation.

At the last inspection we recommended that the registered provider continued to review staff training needs and that staff training was kept up to date. At this inspection we saw that staff had completed appropriate training. People told us they felt staff had the skills to carry out their roles effectively.

At the last inspection we recommended that the registered provider continued to develop support for people to engage in meaningful activities. At this inspection we saw that the availability and variety of activities had improved.

At the last inspection we recommended that the quality assurance systems needed to improve to ensure concerns were identified and action was taken to address these concerns. At this inspection we saw that the manager carried out numerous audits each month. Any shortfalls had been identified and there was evidence these had been considered and improvements made.

At this inspection we found there was a manager in post who was registered with the Care Quality Commission (CQC) and that they were being supported by an acting manager who ran the service on a day to day basis. People who lived at the home, relatives and staff reported that the service was well managed.

Staff had been recruited following the organisation’s policies and procedures and people told us they felt safe living at the home.

People told us they were happy with the choice of meals provided at the home. Nutritional needs had been assessed, people’s special diets were catered for and food and fluid intake was being monitored when this was an area of concern.

Staff were kind, caring and patient. They encouraged people to be as independent as possible and respected their privacy and dignity. It was clear that staff knew people well and this helped them to provide person-centred care.

Staff received training on safeguarding adults from abuse. They were able to describe different types of abuse they may become aware of and the action they would take to protect people from harm.

Accidents and incidents were recorded appropriately and had been analysed to identify any patterns or trends, and any areas that required improvement.

People understood how to express any concerns or complaints and were encouraged to feedback their views of the service provided. We received positive feedback from everyone who we spoke with.

Staff told us they were well supported through supervision and staff meetings.