The Windings extra care service deteriorated from Good to Requires Improvement after inspectors identified breaches of Regulation 12 (medicines management) and Regulation 17 (good governance), linked to the registered manager's departure and incomplete audits. Effective, caring and responsive domains remained Good, with people reporting positive, dignified care from staff who knew them well.
Concerns (10)
critical
Medication management
: “Medicines were not always safely managed. We found examples where records were unclear, inaccurate or incomplete.”
criticalMedication management: “In some apartments, current medicines were mixed up with medicines which were no longer prescribed or out of date.”
criticalGovernance: “Systems were either not in place or robust enough to demonstrate sufficient oversight of records and of the care being delivered.”
moderateMedication management: “There was a lack of guidance for staff to follow when administering 'as required' medicines or prescribed creams.”
moderateMedication management: “Staff had failed to raise concerns or record actions taken when people had run out of medicines.”
moderateGovernance: “Although audit processes were in place, they had not been completed in a timely manner.”
moderateLeadership: “The registered manager had recently left the service and interim management arrangements were in place.”
moderateStaffing levels: “staff working at the service described being short staffed in recent weeks which had caused some pressures within the team.”
moderateRecord keeping: “We found examples where records were unclear, inaccurate or incomplete.”
minorSupervision / appraisal: “due to recent management changes, some staff had felt unsupported in recent weeks.”
Strengths
· Recruitment procedures were safe with pre-employment checks completed before staff started
· Staff used appropriate PPE and had completed COVID-19 infection control training
· Safeguarding referrals were made to the local authority when abuse was suspected
· Care plans were person-centred and reviewed regularly in response to changing needs
· Service worked within the principles of the Mental Capacity Act 2005
Quality-Statement breakdown (20)
safe: Using medicines safely; Learning lessons when things go wrongRequires improvement
safe: Staffing and recruitmentRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Preventing and controlling infectionGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Staff working with other agencies; supporting access to healthcare and nutritionGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships and avoid social isolationGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empowering; duty of candourRequires improvement
well-led: Engaging and involving people using the service, the public and staff; working in partnership with othersGood