Archived: Windmill Lodge

On this page

• 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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question as requires improvement. At this assessment the rating has remained requires improvement. This meant the governance of the service was inconsistent.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The staff and management team had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The new management team promoted a shared vision, strategy and culture. The manager and deputy manager were open and honest throughout the assessment process. A relative told us, “Yes definitely more open and approachable the new managers are doing a very good job.” The provider’s policies and procedures promoted an open and honest culture throughout the service.

Windmill Lodge had inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation.

The management team had systems in place and allocated tasks to senior staff and other members of the staff team. For example, daily diary sheets of people and daily meetings for staff to discuss the day’s events.

Windmill Lodge fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they were aware of the whistleblowing policy and the path to take should they need to raise concerns. A staff member said, “We have recently done our safeguarding update training. “ Another staff member said, “The new manager is more on the ball with training and safeguarding people. “All safeguarding training is up to date.” Staff were aware they could report and concerns directly to the Care Quality Commission and the local safeguarding teams.

The management team valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

The management team had policies and procedures around equality, diversity and inclusion. We found guidance and information was also available in the employee’s handbook. Staff felt the management team considered their equality, diversity and inclusion and treated people equally and fairly. For example, where staff needed to work in a flexible way, this was discussed with the new manager and changes to their working pattern would be made.

The service did not have clear roles, accountability systems and good governance. The provider continued to have ineffective governance systems in place to identify and drive improvements at the service.

Leaders completed monthly audits but failed to identify the shortfalls identified at this assessment.For example, staff training had been identified for improvement through their auditing systems but had not been acted upon. This was in an area of clinical learning and potentially could put people at risk of not receiving appropriate nursing care by qualified staff. However, the new management team had highlighted this from the previous management and were in the process of accessing relevant professional courses to ensure more suitably trained staff were deployed to treat people with nursing needs. One staff member said, “Not enough staff are trained in catheter care and vena puncture care.” The management team assured us no new people would be admitted who required this level of care until staff were suitably trained. Also deployed in sufficient numbers to ensure people were not at risk.

Whilst we did not identify anyone who had come to harm, ineffective monitoring contributed to the continued breach of regulation for governance.

The management team understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The management team and staff collaborated with relevant professionals and agencies. For example, district nurses and general practitioners. Staff communicated and recorded information provided from health professionals when they visited people. This was confirmed by a recent local authority contract monitoring exercise which was ongoing.

The service did not focus on continuous learning, and improvements across the organisation. The provider had not ensured learning and improvement had taken place since the last inspection in relation to areas of concern that had been identified. However, the management team manager was responsive to addressing the shortfalls we identified during the inspection.Action taken by the management team included each staff member to have individual mandatory training schedules that were audited monthly to ensure these were kept up to date. In addition, staff were kept up to date with any relevant training to assist them in their roles.

The management team also took action to address concerns. Whilst we did not identify anyone had come to harm, the lack of improvement contributed to the continued breach of regulation, in relation to a lack of improvements in areas such as quality assurance systems and staff training.