Windward House is a care home registered to provide personal care and accommodation for up to 42 older people. The majority of people who lived in Windward House were living with a form of dementia.

We carried out a previous inspection of this service on 5 and 6 October 2015 where we found improvements were required in relation to several areas. These areas included the management of risks to people, medicines management, the suitability of the environment, the implementation of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. We also found improvements were required with regards to respecting people, personalising people’s care plans, increasing activities for people and ensuring records were kept up to date. At this inspection on 24 January 2017, we found action had been taken to respond to our concerns and improvements had been made.

This inspection took place on 24 January 2017 and was unannounced. At the time of our inspection there were 36 people living in Windward House. People had a range of needs, with most people living with a form of dementia.

The service 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Following our previous inspection in October 2015 the provider had signed up to an initiative called Dementia Care Matters which aims to improve the care home experience for people living with dementia. The registered manager and the staff spoke with obvious enthusiasm about the changes they had implemented at the home and how these were benefitting people. The changes being made related to the ways staff worked, the ethos of the home, the environment and the activities and stimulation available for people. The registered manager and senior managers had also worked hard to improve the quality monitoring and auditing systems within the home. These ensured records were kept up to date and any issues were picked up and acted on without delay.

Directly following this inspection in January 2017 we received some concerns relating to some issues we had looked at during our inspection along with some issues we had not. These related to the management of medicines, the culture of the management, issues to do with hot water, people having access to toiletries and recording issues. Some of these areas had been covered during our inspection, during which we did not find evidence to support the alleged concerns. Where the areas had not been covered, we asked the provider to investigate these issues and they sent us written assurances that people were receiving high quality care in an honest, well managed and supportive environment.

People were protected from risks relating to their health, mobility, medicines, nutrition and behaviours. Staff had assessed individual risks to people and had taken action to seek guidance and minimise identified risks. Where accidents and incidents had taken place, these had been reviewed and action had been taken to reduce the risks of reoccurrence. Staff supported people to take their medicines safely and as prescribed by their doctor.

Staff knew how to recognise possible signs of abuse which also helped protect people. Staff knew what signs to look out for and the procedures to follow should they need to report any concerns. Safeguarding information and contact numbers for the relevant bodies were accessible to staff and people who lived in Windward House.

Recruitment procedures were in place to ensure people of good character were employed by the home. Staff underwent Disclosure and Barring Service (police record) checks before they started work in order to ensure they were suitable to work with people who were vulnerable. Staffing numbers at Windward H

Two adult social care inspectors carried out this inspection. The focus of the inspection was to answer five key questions (Is the service safe, effective, caring, responsive and well-led?) and to follow up on two warning notices which had been issued following our previous inspection in February 2014.

As part of this inspection we spoke with three people who used the service, the Registered Manager, a member of senior staff, two care staff, one domestic staff and one visitor. We also reviewed records relating to the management of the home which included five people’s care plans, four staff files, the home’s policies and procedures, the incident and accident folder, the safeguarding folder and the home’s quality assurance folder. There were 38 people living at the home at the time of the inspection.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

We found that the concerns identified during our previous inspection in February 2014 had been addressed and the non compliance had been rectified.

Is the service safe?

There were systems in place to ensure all staff had received safeguarding training and were aware of reporting processes. There were systems in place to ensure risks to people’s safety and welfare were identified and risk assessments were put in place to minimise such risks. There were systems in place to ensure appropriate procedures were in place in the event of a foreseeable emergency. People we spoke with told us “I feel safe”, “I feel my relative is safe, very much so” and “It’s incredibly safe.”

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. No applications had needed to be submitted by the service, under the safeguards. However, a policy was in place and the Registered Manager told us they knew when an application should be made and had experience of how to submit one.

Is the service effective?

People told us they were satisfied with the care they received. We saw from care records that people’s care needs had been appropriately assessed and care plans reflected these needs. People we spoke with said “The staff look after me well, they get to know you” and “They are good at helping me.”

Is the service caring?

People were supported by kind and attentive staff. We saw that staff showed understanding, patience and gave encouragement when supporting people. We saw that people were able to do things at their own pace and were not rushed. People’s preferences had been obtained by the home and were included in people’s care plans. A number of activities were organised and people were encouraged to participate in these. Where people chose not to participate in activities, one to one time was provided.

Is the service responsive?

Records showed that people’s preferences, interests and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes. We saw records of the home responding to people’s changing needs and seeking advice and guidance from relevant healthcare professionals.

Is the service well-led?

Quality assurance processes were in place in the home. We saw evidence of people and their relatives being asked for feedback and this being responded to and acted on. We saw that several audits and internal inspections had been carried out and that any issues identified had been acted upon. Staff told us they were asked for their feedback and felt their opinions had been listened to and used to improve the home.

We, the Care Quality Commission (CQC) carried out an early morning responsive inspection of Windward House in response to information of concern we had received about the service.

Due to the early hour of the inspection, 5.30am, we did not speak to people who used the service on this occasion.

The information we had received related to the times people were woken up in the mornings, one staff member assisting people when they required two people to support them safely, night time staffing levels and night staff being reprimanded for not getting

enough people out of bed in the mornings. There was also information about fluid balance charts not being completed until the end of night shifts and the food being of poor quality.

We found that people were not being woken up according to their choices. We found a number of people were being woken up during the very early hours of the morning and not being given the choice to wake up in their own time. People's views and choices were not taken into account when delivering their care.

We found night staff had a low morale and felt pressured by management and day staff. They told us this occurred if they did not get a high number of people up during their shifts. This pressure to get a high number of people up meant that on occasion one staff member had assisted people who required two members of staff alone. The provider had not monitored staff wellbeing or assessed the impact this had on people.

At the last inspection in June 2013 we identified concerns with certain aspects of the care records within the home. At this inspection we found significant improvement had been made.

41 people lived at Windward Court at the time of our inspection. We spoke with seven people who lived there and four members of staff. People told us that staff were kind and helpful. Comments included, "You couldn’t get better care “and “It’s very nice here, I am happy.”

People took part in a range of activities and were encouraged to maintain independence.

People and their relatives were involved in planning their care, as much as they wished to be. Where people did not have the capacity to take decisions about their care their rights were protected.

People’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan. Care plans were reviewed regularly and as necessary. Records showed that prompt referrals were made to health professionals and their advice was followed. Procedures were in place to deal with emergencies.

Windward Court was clean, homely and well maintained.

People were cared for, or supported by, suitably qualified, skilled and experienced staff.

There was an effective quality assurance system in place. Records were kept securely but not all were up to date.

We completed this review on 23rd April 2012. We spoke in private with two people living at the home, the manager, three staff and two healthcare professionals.

Because of the complexities of their illnesses, some people were unable to tell us about their experience of living at the home. Therefore both direct and indirect observation was used to assess the wellbeing and happiness of people in the home, as well as speaking with them.

Staff told us how people were encouraged to make their own decisions, especially in relation to how they received the care they needed. We heard people being offered choices about how they wanted to spend their time.

We heard staff speaking with people in a kindly, friendly way and people that we spoke with confirmed that staff always treated them with respect. We saw staff respond promptly, discretely and sensitively to people when they asked questions or needed help.

Each person had a care file that contained a wide range of documents relating to their care and support needs. Each file we looked at contained detailed pre-admission assessments that included details of next of kin and some of the individual's preferences. A range of risk assessments had been completed including those for pressure areas nutrition and moving and handling. Although everyone who lives at the home has a care plan that sets out their needs the care plans do not always contain sufficient information for staff about how to meet these needs especially in regard to their social needs and life experiences.

The home employs an activities organiser and we saw people enjoying a craft session. People told us there was always something going on and they could pick and choose whether they joined in.

During our visit we looked at the communal areas of the home and all bedrooms. Areas that we saw were very clean and tidy and there were no unpleasant odours.

Staff told us that Windward provided staff with a thorough ongoing training programme, which included mandatory training such as First Aid, Food Hygiene and Health and Safety as well as additional specialised training which related more directly to the individual needs of people who lived in the home such as dementia and just recently tissue viability (caring for pressure areas)

Staff that we spoke with told us that they had received training on safeguarding people and they were able to tell us about different types of abuse and what they would do if they suspected abuse was occurring.

Windward House is a care home which provides accommodation and personal care for up to 42 people who may have care needs related to their dementia. People who live at the home receive nursing care through the local community health teams.

The home had a registered manager in post. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

This inspection took place on 5 and 6 October 2015 and was unannounced. At the time of our inspection there were 37 people using the service. People had a range of needs with some people being independent and others requiring more support with their mobility and care needs. A significant amount of people who lived in the home were living with dementia.

The service was last inspected in May 2014 and was found to be meeting all the regulations.

The service was not always well-led. People’s care records were not always accurate and the quality assurance systems in place had not found a number of concerns identified during this inspection. We found concerns relating to risk management, mental capacity assessments, medicines management, the environment and stimulation for people. Feedback from people, relatives, visitors and healthcare professionals told us staff and management did their best to care for people in a caring way but we found the service did not provide an effective and caring environment for people living with dementia.

People who lived in the home were not always safe. People’s medicines were not always well managed. For example, one person was dispensed medicines prescribed to someone else. It was not possible for the provider to assure themselves people were receiving their medicines as prescribed by their doctor. The home had procedures in place relating to disposing of medicines and conducting audits but these had not been followed.

Risks to people were not always well identified, assessed and managed. For example, one person had diabetes and required their blood sugars monitoring twice a day. Their readings fluctuated but staff did not have access to information about what the person’s blood sugar range should be in order to maintain good health. This meant staff were unable to identify whether the person was at risk or if their readings were outside of the norm for them. After the inspection the registered manager consulted with a doctor who provided guidance for staff and undertook diabetes training.

Although staff and the manager felt there were enough staff to meet people’s needs, people and their relatives did not always agree. This was particularly so at weekends and we have asked the manager to review this.

People were protected from abuse as staff had been provided regular training in safeguarding vulnerable adults. Staff knew how to identify abuse and how to report it should they have any concerns.

At least half the people who lived in Windward House had some degree of dementia. The environment was not suitably adapted for people living with dementia. For example, there was no signage to help people find their way around the home and the carpet caused people confusion. People did not benefit from suitable activity to promote their wellbeing. People spent long periods of time sitting in silence and relatives expressed their loved ones were bored.

Staff could not assure themselves that people were getting enough to drink as records were not accurate. People were not always encouraged to drink, for example, one person was provided with three drinks over four hours which were left untouched and removed by staff once they were cold. Staff did not encourage this person to drink. People enjoyed the food but did not feel they had a choice of meal. There were no menus and although staff asked people for their choice in the morning people did not have any memory of this. Staff supported people to eat and the chef catered for specific requirements.

The provider had not followed the principles of the Mental Capacity Act 2005 for those people who did not have the capacity to make their own decisions. Some people did not have mental capacity assessments in their care plans where these were required. It was not clear how people’s care and treatment was carried out in their best interest where they lacked capacity to make decisions about their care themselves. The registered manager did not have a thorough understanding of the Deprivation of Liberty Safeguards (DoLS), they had not applied the ‘acid test’ to determine whether further application needed to be made to the relevant authority. The acid test is where a person is subject to continuous supervision and control and is not free to leave.

People were cared for by staff who had received a thorough induction and were provided with regular training, Staff received a yearly appraisal and regular supervisions.

People were not always treated with dignity and respect. For example, one person, who was proud of their appearance, was left in communal areas in their night clothes for four hours. For three of those hours they were placed in their wheelchair at a table facing the wall with no stimulation or companionship. When staff moved the person from that position they did so by pulling their wheelchair from behind without first speaking to the person or telling them what they were doing. On other occasions we saw very positive interactions between people and staff and people, relatives and healthcare professionals gave consistently positive feedback about staff.

Care plans lacked personalisation and many did not contain information about people’s personal histories, their preferences, likes and dislikes. Staff, however, demonstrated they knew people well.

People and relatives had access to the complaints procedure and felt comfortable approaching the staff and the management with any concerns they may have.

Records were not maintained accurately, for example, one person had been living in the home for almost three weeks at the time of our inspection and did not have a care plan. Staff did not have instructions on how best to care for this person.

Audits had not always been carried out in order to identify possible issues. For example, a medicines audit had not been carried out and we found some discrepancies with quantities and disposal of medicines.

People, relatives, staff, visitors and healthcare professionals spoke very highly of the registered manager and felt they were approachable. Feedback was sought from people and their relatives in the form of questionnaires and meetings. Staff were asked for their feedback during meetings, handovers and supervisions.

We have made a recommendation for the provider to review their staffing numbers.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.