Windmill Manor

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, the ways people’s medicines were managed safely, poor infection controls, people being protected from the risk of abuse, the lack of adherence to the Mental Capacity Act and staff levels, training and supervision.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

There was a lack of robust management around accidents and incidents to minimise the risks to people. For example, we saw from incident reports between 1 February 2026 and 14 April 2026 there were 18 recorded incidents of unexplained skin tears and bruising to people. Although the records stated action was immediately taken by staff, the leaders failed to ensure that these incidents had been analysed fully or routinely investigated for themes and trends. There was no evidence they considered whether how staff moved and handled people needed to be reviewed to reduce further risks to people. This meant they missed opportunities to put in place necessary action to reduce further incidents and prevent avoidable harm or risk of harm to people.

We saw from care notes where staff had recorded occasions where a person was found in another person’s room during the night. Staff had not always reported these issues as incidents and there was no evidence that leaders routinely reviewed people’s care notes to identify emerging safety risks. This meant these concerns were not being recognised and risks to people’s safety were not being mitigated.

The service clinical governance meeting minutes for March 2026, monthly trends and themes were reviewed for falls. It was recorded, ‘No trends of times identified…’ However, the data used did not reflect the incident forms had been completed by staff so the analysis of this would not have been accurate. The minutes stated there had been 4 falls [2 with a significant injury], however there had been 6 falls. There was also no information recorded to conclude there were no themes and trends which could have included the time of day and whether staff deployment had been considered.

While some relatives told us they were informed following incidents, this did not mitigate the lack of effective systems to identify, investigate and learn from safety events to prevent recurrence.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

Whilst the leadership team had undertaken assessments of people’s needs before they moved into the service, these were not always detailed and did not always provide guidance for staff on how to support people in a safe way. For example, 1 person’s assessment had been completed in the hospital with a member of staff. However, the person or their representatives were not included in the assessment. The booklet used to determine their needs was also not fully completed including preferences and the level of dependency in each key area of care. In addition, the ‘review of information by the general manager’ had not been completed or signed by the registered manager.

Another person had been admitted to the service without full information about the distressed behaviours. The registered manager had recorded the person’s ‘as and when’ agitation medicine was stopped before the person left the hospital. There was no record this had been discussed or risk assessed following the home finding out about this. Abruptly stopping a person’s ‘as and when’ medicine for agitation lead to significant side effects for the person due to their dependence on the medicine, making a gradual, supervised reduction safer. It was also difficult to know, whether without this medicine, the service would be able to safely meet the person’s needs or whether this was explored by the registered manager. The incident records showed the person had experienced multiple incidents of distressed behaviour since moving to the service including hitting a person and staff. A third pre-assessment took place over the phone with a member of staff from their previous care setting. There was no evidence the person or their representative had been involved. A thorough pre-admission assessment is required to determine if the service can safely meet the needs of the new person without compromising the well-being of other people. We found this did not take place which placed the person and others at risk.

However, there were relatives felt the admission process went well for their family member. One relative told us, “It’s been brilliant. Even when he first arrived, he was going up to staff, and they knew all about him.”

While some relatives reported a positive admission experience, this did not mitigate the lack of effective assessment, partner engagement and continuity planning required to ensure people’s safety following admission.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

One person told us there was a difference between the day and night staff in relation to how they were towards them. They told us, “At night they don’t talk to me, they just say ‘turn’ [in relation to them being repositioned].” A relative told of us about their loved one, “I pick up that it’s the night staff he’s not so keen on. He’s said it a few times.”

Relatives of people told us they did not feel their family members were always safe at the service. Comments included, “I worry about incidents, there are a few new [residents] that are aggressive”, “People kept going into his bedroom and dumping things in there” and “There’s a [person] who is always asleep in other people’s beds”.

There were no effective processes in place to ensure people were protected from the risk of abuse, or avoidable harm and some people had suffered abuse. When incidents of abuse occurred, leaders did not consider the emotional impact on the person, other people and staff. We saw 2 incidents where each person had assaulted other people. Leaders had not taken sufficient action to investigate the abuse or taken action to protect people from further abuse. One member of staff said, “Upstairs is dementia and I think the upstairs floor needs to be separated as it frightens some people.” The registered manager told us regarding incidents of distressed behaviour, “You can’t always foresee what’s going to happen.” However, knowing this, leaders had not taken robust action to protect people from the risk of further abuse. We requested the provider acted urgently to address these concerns and advise CQC of the actions they had taken. We will assess the effectiveness of this at the next inspection.

We saw from care notes that there were incidents of unexplained bruising and injuries to people who were unable to verbally communicate how this happened due to their cognitive decline. Leaders had not undertaken a detailed investigation to determined how this occurred. They often closed the concern stating it was likely this related to the person ‘walking with purpose’ and injuring themselves on furniture.

During both visits to the service, we frequently observed people going into other people’s rooms [whilst the person was in there]. Care records also stated people may go into other people’s rooms however there was no risk mitigation in relation to this. In one instance we observed a person cared for in bed was calling out when another person was in their room. Care records showed staff had to encourage people out of other people’s bedrooms but there was also a risk that staff would not always know when this was happening. People with dementia may wake up confused to find another person in their room, causing distress and anxiety. We also noted multiple incidents where people had hit staff or attempted to hit staff. The leaders had not taken sufficient robust action or preventative measures to reduce any further risks to people.

However, there was feedback from some relatives that was positive, including, “It’s absolutely safe, it’s ideal. They keep him safe” and “I am very happy. Yes, he’s safe here” and “He’s safe where he is no and it’s a huge weight of my shoulders.”

While some relatives reported feeling reassured about safety, this did not mitigate the significant risks identified or the lack of effective systems to prevent abuse and protect all people from harm.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met.

Leaders did not consistently adhere to the principles of the Mental Capacity Act 2005 (MCA). As a result, some people were subjected to restrictions without the appropriate legal authority.

We found there were people that had covert medicine protocols in place. (This is the administration of medicines disguised in food, drink, or via other means without the person’s knowledge or consent) However the protocols were not specific to the person and 2 we reviewed were identical. It was not clearly recorded why it was in the person’s best interest to have their medicine this way or that it was important to try and give medicine overtly in the first instance. The provider has now confirmed that action has been taken to address this.

There were videos and photos of people living with dementia being used on the service’s social media site. There was no evidence that capacity assessments had been undertaken in relation to this. Services should avoid posting people’s images on social media to protect their dignity, privacy, and legal rights.

There were other restrictions in place such as locked doors and bed rails where capacity assessment and best interest meetings had been recorded appropriately..

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Some relatives told us they did not feel the risks associated with their loved one’s care were being managed safely. Comments included, “[Staff are] totally blind to risk. They bring people down [from memory lane] and [person] grabbed me and [staff member] was blind to all that. People come down and it’s a risk” and “Nurses don’t monitor his health. There have been a few occasions where he has fallen ill, and this could have been prevented.”

Where people were at high risk of developing pressure sores, some care plans stated the person needed to be repositioned every 2 hours. However, staff were not consistently recording doing this. For example, for one person, over a 12-day period, the person’s repositioning for the majority of the time had not been recorded as taken place for over 8 hours or more. One relative told us, “[Person] has had red skin, they are supposed to turn her every 4 hours, but I don’t think they do that.” Another relative said, “[Person] has had a red area, and they are putting cream on that.” However, this person was also required to sit on a pressure cushion, but we observed this was not happening.

Where people were at high risk of constipation, staff were not routinely recording when they had opened their bowels. For example, according to their care notes 1 person was at risk of constipation and staff were required to monitor their bowel movements. The care notes between 31 March and 13 April 2026, showed staff only recorded a bowel movement on 3 of these days. This placed people at further risk of constipation.

Other health risks associated with people’s care were not always being managed well including [but not limited to] the risk of choking, hydration, distressed behaviours and catheter care. Risk assessments did not always reflect the most current needs. This meant staff may not provide the most appropriate safe care.

The Behaviour Support plans in place for people did not have sufficient guidance for staff on how to support people when they had incidents of distress. There was a lack of information on what may trigger people’s distress or how staff needed to respond when the person was directing their anxiety towards people and staff. This placed the person, staff and others at risk of harm.

The provider did not always detect and control potential risks in the care environment. They did not make sure equipment, facilities supported the delivery of safe care.

We found there were elements of the environment were not set up safely to meet the needs of people living with dementia. There was a lack of appropriate signage or identifiers in the service to help orient people to their own rooms. This is essential for safety because it enhances independence for people and may help prevent people from entering other people’s rooms.

We found where people’s had bed rails, when they were not in use they were locked down. However, the top of the bed rail protruded above the mattress making it uncomfortable for people to sit on the edge of their bed. One person told us the back of their legs hurt when they sat down on the bed. We also tried this and agreed this was uncomfortable. This placed people at risk of bruising and skin tears to the backs of their legs.

Another person had their call bell around their neck which was found trapped underneath them, meaning they wouldn’t have been able to use it, and it may have been a ligature risk. We raised this concern with staff who the assisted the person with this. A relative told us they said they had been raising concerns with equipment for some time and “Been complaining for over a year and it’s still like that. They take so long to fix anything.”

We did find regular other Health and Safety checks were undertaken by the maintenance team including water temperature, fire safety and legionnaires. All people had an up-to-date Personal Evacuation Plan in the event of an emergency such as a fire.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

People and relatives fed back there were not sufficient staff. Comments included, “Not [enough staff] when you want one”, “It varies, occasionally it’s obvious they are down a person. [Family member] is left with her pads a long time” and “It looks better than it is, it’s gone downhill. There are not enough carers, 3 during the day and 2 at night, that’s just not enough.”

The registered manager told us 4 carers, and a nurse were required on the ground floor and 3 carers and a nurse for the first floor and there was an additional care staff member who would float between each floor. However, the extra member of staff provided 1-1 support for 1 person for 8 hours of the day. This meant the additional member of staff was only available to support on either floor for 4 hours of the day.

On both days of the inspection, on the first floor we observed people frequently going into other people’s rooms without staff being aware. On day 1, a person stood by another person’s bed and was removing their continence aid until we intervened. On day 2, we observed 2 people going into others’ rooms and pushed and pulled furniture around unseen by staff for approximately 15 minutes. A member of staff told us, “It’s very hard upstairs. Even though there are 10 empty beds, everyone has high needs. The other day [person] was lying on someone’s crash mat [in another person’s bedroom] and he refused to get up. It took 20 minutes and 4 staff to eventually get him to agree to get up.”

Staff also stated there were not enough staff on duty. Comments included, “Not enough staff, it amazes me how they do it. They are rushed off their feet; I hear it from all the relatives. They say, ‘I can’t find a member of staff”, “Three[staff], it’s not enough though as people have dementia. We can’t stop people going into other rooms, but we will try and get them out” and “The 1-1 comes in the morning from 08.00 to 12.00 and then goes downstairs to the 1-1 12.00 to 20.00. To me 3 is not enough. We have people that need intensive support and we struggle to do that.”

Whilst the majority of care staff received their mandatory training, this was not always effective in ensuring good care. Staff told us they did not always feel confident in how to manage when people had distressed behaviours and were hitting out. One member of staff said when asked what training they are given on this, “I don’t know really. [we are told] ‘a change of face, ask for advice?’ I wouldn’t want to be up there on my own. We’ve not had any real training.”

Whilst nurses received 1-1 clinical supervision, they lacked substantial discussions around clinical care. In addition, there had been no permanent nurse who the clinical lead at the service for several months. Although we were told a provider’s Clinical Development Nurse (CDN) attended the home, they were not permanently based there and was only present 2 days a week.

There were people and relatives who felt there were enough staff, comments included, “I don’t think there is a problem with staffing. I have never noticed an issue”, “I can use my bell (showing me it was on his bed). Staff dote on me” and “There’s a lot of staff there as well, enough for everyone and they seem to understand dementia well.”

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Relatives fed back the cleanliness of the service was not good. Comments from relatives included, “Some [staff] turn a blind eye to changing people’s pads. It stinks in this place” and “You can smell urine; I had to throw her wheelchair cushion away as it stunk.”

People were placed at risk as the provider had failed to ensure good infection, prevention, control practices. We found there had been recurring scabies at service since October 2025 and appropriate steps had not been taken to manage this. Providers should ensure suitable accurate information on infections to people; their visitors and staff is shared in a timely way. However, relatives and staff told us they had not been made aware scabies had been identified at the service again. A relative told us, “Scabies is going round and we have only just found out yesterday. I have seen a couple of people scratching.” A member of staff told us, “I wasn’t told anything, it caused quite a bit of aggravation. We’ve had it a few times, people in the home still have it. Staff were affected as well; it caused a lot of upset with staff as they were not told as well.”

Sharing this information is vital to ensure that staff follow appropriate infection controls to reduce further risks. One member of staff told us, “A carer has used a green bag [for laundry] up here [first floor] today which indicates an infection. I don’t know if anyone does have an infection up there.” The registered manager told us, “No infection on the 1st floor that would warrant green bags.” However, this was not the case, and it was recorded in a care note the GP had confirmed at least 1 person had been diagnosed with scabies on the 12 April 2026. There was also reference to 2 people with scabies in the staff handover notes between the 6 and 10 April 2026.

In addition to this, a person had been diagnosed with an infectious condition, we were told by staff this was the day prior to our first visit. This had not been shared with all staff in the home, and it was not after 11.30 [after we had already gone into the room] a sign had been placed on the person’s door to warn visitors and staff of the infection. The registered manager told us, “I wasn’t aware of the [infection] until 11.30.” However, on checking the person’s care notes, they had been diagnosed with this on the 12 April 2026, 2 days prior to our visit. A member of staff told us about how they were made aware, “[Person] told me because I didn’t know. I do know [person is] in isolation now.”

We also noted people were infrequently being provided with a shower or bath. One relative told us, “There are times when he has an odour about him which he shouldn’t. I think it’s when the night staff do his personal care. I think they might just give him a wash, rather than a shower.” According to the care records over a 2-week period, 1 person did not have a bath or shower, another person who liked to have a shower every day, was only showered 4 times over the same period.

We identified the smell of urine on and off when we arrived at the service on both floors on both days of our visit. A member of staff told us, “For what they expect to be done there is not enough [housekeepers]. As well as bedrooms [housekeepers] have the back stairwells, outside lift, staff room.” They said, there was a delay with care staff telling housekeepers when a person had been incontinent and, “Care staff are not good at bagging up. Bags have to be tied up when they are placed in the trolley.” They said staff don’t always tie them up, so this is what often causes some of the urine odour. The registered manager told us plans were in place to replace carpets in the corridors on the first floor.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Whilst there were some people who received their medicine as prescribed, there were elements to the management of medicines that were unsafe. We saw from the care notes a GP had confirmed a person had a mouth infection and prescribed them medication. However, it was a further 24 hours before staff started to administer the medicine to treat this. In between this staff had recorded the person was spitting food out which could indicate the person found this painful or uncomfortable due to the infection.

We found people’s ‘as and when’ medicines lacked person centred detailed guidance for staff on when they needed to offer the person the medicine or there was no guidance in place at all. This is particularly important given most people had advanced dementia and may not be able to articulate when they were in pain. Examples included, 1 person was prescribed ‘as and when’ sedative at night and also a pain relief medicine. Both had been given daily to the person since 6 April 26. However, there was no ‘as and when’ guidance in place for staff. There was also a lack of recording by staff on why this had been administered. This meant there was a risk the person was given medicines when they were not required.

Another person had been prescribed ‘as and when’ medicine for agitation. The guidance for staff was limited to giving it to the person for ‘agitation’. It went on to state staff are to try to assure and calm the person first. However, it was not clear at what stage staff were to administer the medicine. This meant there was a risk the person was not always receiving their medicines when needed.

Since the inspection, the provider has confirmed that more detailed guidance has now been included.

In addition to this, we found ‘as and when’ protocols included recording errors in the spelling of people’s names and referring to the person’s gender incorrectly.

We observed controlled drugs (CDs) were not counted as the white boxes [that were taped shut] delivered from the pharmacy had not been opened. This meant the actual number inside each box had not been checked when booking in the medicine, and when undertaking daily checks which noted the quantity. There was also a risk the glass ampules could have become damaged inside the white box.

People’s ‘as and when’ seizure medicine guidance contained no information on the type of seizures, how long they may last, how to recognise signs, or when to contact 999. The guidance also did not direct staff to the person’s epilepsy care plan. After the inspection, the provider sent us evidence that more detailed guidance was now in place in relation to this. People’s non-medicated prescribed moisturising creams lacked guidance including when it should be applied, the reasons and where it should be applied. It just stated, ‘Use as directed.’

However, some areas of medicines were managed well. The medicine rooms were kept clean and tidy and temperature checks were undertaken in the rooms. There was good management of the stocks of medicines (aside from CDs as mentioned), and medicines related to Parkinson was well managed. People were also routinely having their blood sugar levels checked in relation to their diabetes.