This unannounced inspection took place on 10 September, 30 October and 6 November 2018. Our first day in September was cut short as some people living at the home were unwell.

We last inspected the home in May 2017. We found significant improvements had been made to improve the overall quality of the service. However, further improvements were still required to improve the safety of medicines, staff training and competency on the Mental Capacity Act 2005 and the effectiveness of quality assurance procedures. We reported the provider had breached the regulation relating to Good Governance and rated the home Requires Improvement overall.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key question, is the service well-led, to at least good. At this inspection we found the provider had continued to make improvements to the overall quality of the service. Quality assurance checks were completed consistently and were effective in identifying areas for improvement. People, relatives, staff and health professionals gave us good feedback about the registered manager.

Windsor Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Windsor Care Home accommodates 60 people in one adapted building. There were 47 people living at the home at the time of this inspection, some of whom were living with dementia.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People and relatives gave consistently good feedback about the home and the care provided. Staff and visiting health professional gave similarly positive feedback. Throughout our time at the home we observed positive interactions between people and staff.

People said they felt safe living at the home. Relatives and staff also felt the home was safe. Staff had a good understanding of the procedures for keeping people safe. For example, safeguarding and the whistle blowing procedure. They knew how to report concerns and said they wouldn’t hesitate to do so if needed.

Although we observed there was a visible staff presence around the home, we received some mixed feedback about staffing levels. Management felt staffing levels were appropriate. However, the provider did not have an effective approach to monitoring and reviewing staffing levels. We have made a recommendation about this. The provider had effective recruitment procedures to ensure new staff were recruited safely.

Medicines were managed safely. People told us they received their medicines when they were due. Records showed medicines were received, stored and disposed of correctly.

The provider completed health and safety checks and risk assessments to ensure the environment and equipment were safe. There were also up to date procedures to keep people safe in emergency situations. Staff members raised a safety issue with us about using hoisting equipment with certain specialist beds. The registered manager advised that options had been considered but had not been appropriate. However, we noted this issue had not been formally risk assessed to confirm people and staff were safe. The registered manager confirmed a risk assessment would be completed straightaway.

Staff supported people who displayed behaviours that challenge with sensitivity. Staff understood people’s needs and knew the most effective strategies to follow when people were anxious.

The provider had good systems to investigate and monitor incidents

This unannounced inspection took place on 22 May 2017. This meant the provider, staff and people using the service did not know that we would be carrying out an inspection of the service. We returned on 23 and 31 May 2017 to continue with our inspection; these dates were announced.

We carried out a previous inspection on 9 and 11 May and 4 June 2016 at this service where we found that people were not receiving safe care. The service was rated inadequate and placed in special measures. We found people were not protected against risks to them and their rights had not always respected. Medicines had not been safely managed and there were insufficient staff on duty. Staff had not been supported to deliver safe care. Quality assurance systems were ineffective.

We previously carried out an inspection of this service on 12 and 13 October 2016, where we rated the service inadequate and the service remained in special measures. CQC had cancelled the registered manager’s registration. People remained at risk of harm and their rights were not respected. The management of medicines remained unsafe. Staff had not received the support they needed and people did not have access to regular drinks and snacks. Quality assurance procedures remained ineffective because they had not resulted in improvements.

We previously carried out an inspection of this service on 14 and 15 December 2016. Improvements had been made and the service was taken out of special measures. However further improvements were needed to improve the safe management of medicines, staff training and competency in following the principals of the Mental Capacity Act 2005. Ineffective quality assurance procedures remained.

Windsor Care Home provides residential and nursing care for up to 73 older people, including people who may be living with a dementia type illness. There were 43 people living at the home at the time of this inspection.

At the time of this inspection, a new manager was in place and they had submitted an application to become a registered manager with the Care Quality Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At this inspection we found that significant improvements had been made to improve the overall quality of the service. People, their relatives and staff expressed their satisfaction about the improvements at the service. They felt listened to and had been kept up to date with changes. People were much happier living at the service and staff told us they enjoyed their jobs. Staff told us the manager was supportive of them and overall they felt the service had significantly moved forward. More effective quality assurance process were in place, however these required further development as not all had identified areas for improvement had been fully completed. This meant that the service needed to make further changes to be well-led.

Staff understood the procedures they needed to follow to ensure people remained safe. Systems were in place to monitor people at risk, however staff had not always taken continuous action to minimise these risks and improvements were needed to the premises. Robust recruitment procedures were in place for new staff and there were enough staff on duty at all times. Medicines were managed safely. Further improvements were needed to ensure people received safe care.

Staff were supported to carry out their roles by way of regular supervision, appraisals and training. Staff understood and followed the principles of the Mental Capacity Act 2005 and best interest decisions had been made. People had received support with their nutrition and hydration and people had regular access to health and social care professionals when they

The last inspection of this service was carried out on 9 and 11 May and 4 June 2016. At that time we found the provider was failing to meet legal requirements. The provider had breached Regulations 9, 10, 11, 12, 13, 14, 17, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

During the previous inspection we concluded people who used the service were not safeguarded because incidents were not reported or acted upon. People were not fully protected against the risks associated with medicines because the provider did not manage medicines appropriately. People were not protected against the risks associated with infection because of inappropriate staff practices relating to hygiene. People were not protected against the risks of receiving unsafe care because care was not planned and delivered to meet their individual needs or risk assessed to ensure their safety and welfare.

During the last inspection we also found people’s dignity was not being upheld. People’s capacity to make decisions and their consent were not always sought in line with legal requirements. People's hydration and nutritional needs were not being managed in a way that was safe or met their needs. The service failed to deploy enough staff across the home in order to safely meet the needs of people who used the service. Staff had not been subject to robust recruitment processes and checks. Staff had not completed the appropriate training to enable them to carry out their roles effectively. The provider’s quality assurance systems were ineffective and did not make sure people received a safe and good quality service.

We carried out this inspection on 12 and 13 October 2016. The first day of the inspection was unannounced so the provider and staff did not know we were coming.

Since the last inspection the registered manager had left and their registration was cancelled by CQC. A new manager had recently taken up post and was in the process of applying for registration. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

During this inspection we found there were continuing breaches in relation to six regulations. Potential risks to people's well-being were not assessed or set out so staff had no guidance about how to manage those risks. For example there were no risk assessments about potential choking for people who had swallowing difficulties.

Medicines were still not managed in a safe way. This was because people did not always receive their medicines in the right way and records had not been completed correctly placing people at risk of medication errors.

People were still not always being supported to meet their nutritional needs in a safe way. Some people were being given the wrong texture of food which could present a choking risk. People did not have access to drinks whenever they wanted which did not promote good hydration.

During this inspection we found that where people may not have capacity to make decisions around their care, staff had not always completed capacity assessments to check or carried ‘best interest’ decision meetings with others. For example if people used a lap belt whilst they were in their wheelchair, we could not find evidence of whether they consented to this or documented capacity assessment about whether this was done in their best interests.

There were still significant gaps in training of care staff and competency checks of nurses, although there were plans for improvement in this area. The new manager had begun to plan one-to-one individual supervision sessions for each staff member. However, only senior members of staff had had these so far.

The provider’s quality assurance processes were sti

We carried out this inspection to check that improvements had been made in respect of shortfalls in the premises identified on our previous visit on 13 February 2014.

During our inspection on 21 May 2014, we also checked that other essential standards of quality and safety were being met. We considered all the evidence we gathered under the outcomes we inspected. We used the information to answer the five questions we always ask:

• Is the service safe?

• Is the service effective?

• Is the service responsive?

• Is the service caring?

• Is the service well led?

Below is a summary of what we found:-

Is the service safe?

We spoke with six people who used the service and three relatives to find out their opinions of the service. We also sought the opinions of the local authority team which commissioned services from the home. All spoke positively about the service.

People were treated with respect by the staff. Appropriate arrangements were in place to manage medicines and we considered that people were protected from the risks associated with their use.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. The provider had made two applications under these safeguards and notified CQC about this. These applications had been approved by the responsible local authority. We found proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made and how to submit one.

We saw that risks to people’s safety had been identified and assessed to ensure that appropriate care and support was provided to keep people safe. For instance, some people had low beds and safety mats placed by the beds to reduce the likelihood of serious injury if they were to fall from their bed.

Appropriate checks were undertaken before staff began work which helped ensure that the staff were fit and appropriate to work with people in a caring capacity.

The provider had implemented effective audit processes, to ensure the service was safe and to identify ways to improve. These included checks on the premises to make sure they were safe for people to use.

Is the service effective?

We found that people who were using the service received the care and support they needed. The staff we spoke with could describe how they met people’s needs. People’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan. One person who used the service told us, “It’s smashing.” A visitor told us, “This is the best (my mother) has been in; she is getting properly looked after.”

People were happy with the care that was delivered, and particularly the social stimulation provided by staff. A relative commented, “There are lots of activities; sing-alongs, entertainers and outings.”

Appropriate arrangements were in place to manage medicines. People were satisfied with this aspect of their care. One person who had Parkinson’s disease told us, “I get my tablets on time.” Her symptoms were controlled well because her medication was administered on time. A relative of another person commented, “The staff make sure what medicines she needs are taken.”

The provider had taken steps to provide care in an environment that was suitably designed and adequately maintained. The building provided good access throughout for people with physical disabilities. We also noted that the first floor had been decorated with consideration of the needs of people with dementia. For instance, bedroom doors were painted in different colours and had identifying objects or photos to help people locate their rooms. People who used the service commented, “My room is small but it’s comfortable. I brought some of my own furniture” and “It’s small but it’s enough for my needs. I brought my own settee and television.”

Is the service responsive?

We observed that staff provided personalised care and support and they respected people’s wishes and their agreed plan of care. People and their families were encouraged to be involved in making decisions about their care and treatment. A relative told us, “The manager came to meet my mam and the family and the doctor and went through all mam’s care notes. There’s been some tweaking of her care plan since then regarding medication.” This showed that the staff responded to people’s needs as they changed.

We found the premises were maintained and repairs carried out promptly. Visitors told us, “He (the maintenance person) is always working at something” and “He is good. He sorts everything out; like if the television isn’t working.”

Relatives told us the management and staff were open and friendly and they felt confident about raising any issues or concerns with them. A relative commented, “If I had any complaints, I would tell the girls and things would happen.” Another told us, “Anything medical, I speak to the nurses. I know I can speak to them and the manager is always available. She would listen. She is very amenable.”

Is the service caring?

We saw that people were treated with dignity and respect by staff, who were friendly and considerate. They were attentive to people and spent time talking with them to reassure and occupy them. There was a pleasant, welcoming atmosphere in the lounges where people spent time. People who used the service told us they were well cared for. One commented, “They don’t boss us around. They treat us all alike. There’s no favourites. If they can help you, they help you.”

We spoke with three relatives who were all impressed with the quality of care. Their comments included, “The staff are always helpful and generally caring” and “Staff are very caring.”

Is the service well led?

The service had been managed by the same person for over seven years which helped provide consistency. Staff felt supported by her and people we spoke with felt the service was managed effectively. A relative told us, “Things are up to scratch.”

There were effective quality assurance systems in place. Audits were carried out to check people were cared for appropriately, for instance in respect of their physical wellbeing and nutritional status. Medication systems were audited to ensure staff were following safe practice. Audits of the premises were carried out to make sure people were cared for in a safe environment.

During our previous visit we identified that the provider was not maintaining some parts of the home in good physical repair and condition that facilitated the prevention and control of infection. During this visit we found that people were protected from the risk of infection and processes were in place to make sure the home was clean and hygienic.

We found that although regular maintenance was carried out, some areas of the home were unsafe and unsuitable for the regulated activity. These were communal bathroom and shower areas.

We spoke with a number of people and their relatives throughout the day both in their bedrooms and in small groups sitting in the lounge. They told us they were happy with the service provided by the staff. One person said "Things are alright and I like it here". Another said “The staff are what makes this home, they are lovely and really pleasant and supportive".

Staff members were seen to interact well with people and knew them by their first name. There was a choice in what people wanted to do and the privacy and dignity of residents was respected as we observed care interventions being carried out. Staff spoke to people in a pleasant and respectful manner.

People had been individually assessed to see if they could make their own decisions. Care records had enough information so staff would be able to know how to support each person in the right way.

We found that the provider was not maintaining some parts of the home in good physical repair and condition that facilitates the prevention and control of infection.

We saw on the day of our visit, there were sufficient qualified, skilled and experienced staff to meet people’s needs.

There were systems for auditing and monitoring the service. For example audits, meetings with people using the service and their families and with staff. Surveys were also carried out. The records of these processes were up to date and gave the manager and staff members the information they needed to run the home effectively.

People who were able told us they were happy with the care they received and liked living at the service. Three visitors to the home we spoke with told us they were satisfied with the care their relatives received and they had no concerns. Relatives told us they liked how the care staff always made them welcome and how any concerns were passed to the senior staff members if they could not resolve it easily themselves. Because some of the people we saw living at Windsor care home could not give their verbal opinions on the services they received we decided to undertake a Short Observational Framework for Inspection (SOFI) exercise during the lunchtime serving of meals. SOFI is designed to be used when inspecting services for people who had some difficulty in communicating their opinions on the services they receive.