Windmill Manor

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 good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to complaints and governance at the service.

This service scored 32 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

There were relatives who felt that some of the care by staff was not what would usually happen particularly as they visited frequently. One relative said, “They don’t often get wine [with lunch]. That was clearly laid on because you were here." Although we were told by the registered manager only 1 housekeeper was on each floor during the day, an additional housekeeper had been brought in from another of the provider’s care homes after we arrived at the service on day 1.

We found leaders of the service did not demonstrate the required experience or capability to deliver person centred care or to ensure risks were well managed. They failed to recognise they had developed a culture that did not robustly promote or uphold people’s rights to be free from abuse and neglect. Comments from relatives included, “They [leaders] listen but it’s hit and miss whether they care enough…. staff seem unhappy and dissatisfied” and “I’ve learnt the only way to get a response is to put everything in writing.”

The culture of the home was not based on the promotion of learning and improvement. There was a lack of observations of staff practices to ensure staff received the support and feedback about their performance to help drive improvements in the home. A member of staff said, “Most of the time [registered manager] sits in their office and when she does come up, she will just speak to the nurse.” We saw from the care notes one person’s room was searched by staff when they suspected the person may have been smoking. There was a lack of consideration this was the person’s room, and they should have recorded whether or not the person had given consent from the person [who was present] before they did this. This incident was signed off by the registered manager as condoning this. We also observed 2 people lift their jumpers up to expose their stomachs in preparation for the member of staff to administer their insulin injections. This was done in the communal lounge with other people around. This compromised the people’s dignity and privacy. It was also likely this was standard practice given people lifted their clothes in preparation.

Records used undignified language in relation to people including people wearing ‘diapers’ and ‘nappies’. We also noted a record made by the registered manager in relation to presentation of a person who was highly medicated in hospital as ‘presenting almost like a zombie.’

There were relatives that fed back positively about the care their loved ones received. Comments included, “She has a glow now and looks so much healthier and “The day staff are amazing. I feel real connections with some of them and they know him. They are attentive” and “You see the manager around quite often and she will ask how things are going. She’s very approachable. It’s a nice feeling there, very calm.”

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

We found there were incidents of distressed behaviours by people against staff, where staff had been hit and people had used distressed language towards staff. However, there were no formal debriefs by the leaders. Debriefs immediately following incidents where staff are hurt by people should focus on both the emotional well-being of the staff and practical learning to prevent recurrence. They should be conducted as soon as possible after staff have recovered their composure, aiming to create a safe space that fosters recovery, identifies triggers, and reviews the effectiveness of current care plans. The registered manager told us these debriefs did take place however there was no evidence of this. A member of staff told us, “The last time I got hit I informed the nurse, I cried, my head was spinning. The nurse gave me paracetamol. There was no debrief. The manager didn’t come and see me. I felt neglected and that they didn’t care.”

We found the leadership team was not always open and transparent with CQC. This meant professionals and people’s representatives were not always in receipt of information to make an accurate judgement about the quality and safety of the care provided, which put people at risk. For example, the registered manager told us 1 person had moved from the service due to the person having a mental health crisis and the person had called the police. However, the incident form makes no reference to the person calling the police only that staff had been called due to the member of staff not feeling safe. The registered manager told us 1 member of staff supported on both floors and was the ‘floater’. However, this member of staff was funded by the person’s family for 1-1 support with their relative and only supported other staff on 1 floor for 4 hours a day. The registered manager also told us there was no infection on the first floor however according to records, scabies had reoccurred on floor since at least March 2026.

The registered manager lacked knowledge of people’s needs. We suggested the registered manager may want to have a colleague with them whilst we asked for information about people’s needs. They said they did not need this and said they could give us the information we needed. We asked for this information to assist us in following up on people’s care and to check whether their needs are being met. However, the registered manager gave us some incorrect information stating no people received rescue remedy for epilepsy or medicine for Parkinson’s. They stated no people were on thickened fluids and only 3 people were losing weight. All of this information was incorrect meaning the registered manager lacked knowledge of people’s needs and such lacked robust oversight.

There were staff who said they felt supported by the management team. One told us, “I like [registered manager] She’s hands on, approachable and she has an open-door policy.”

Leaders did not ensure that when people, their representatives and staff spoke up, their voices would be heard.

We saw relatives had raised complaints about a variety of concerns including infections in the service, issues with people living at the service being aggressive towards their family members, poor infection control and lack of prompt action to address people’s health concerns. Leaders had noted on the complaints records relatives were satisfied with the response. However, there was a lack of evidence of full investigations taking place and we continued to find these concerns. This indicated lessons were not learnt from these complaints. Relatives are often the primary advocates for people who cannot speak for themselves, making the dismissal of their voice a violation of the person's rights. This meant they were not fully listened to and the lack of action to reduce further concerns points to poor practice by staff that is entrenched.

However, there were staff that felt could speak up with comments including, “I feel supported and comfortable speaking up. There is good teamwork” and “I feel supported and listened to by the manager and unit manager. They will change things if we raise them.”

The provider did not consistently value diversity across their workforce or apply inclusive practices equitably. While leaders demonstrated an understanding of diversity and made some reasonable adjustments, this was not applied consistently, and staff did not always experience fairness and equity in practice.

There were staff that felt they were not listened to. One member of staff said, “I sometimes feel I don’t have a voice or that I have an attitude problem.” Another told us in relation to the stress they deal with managing people’s distressed behaviours, “All management say is that we have to record it. They’re obsessed with ABC charts.”

However, staff told us their cultures and differences in backgrounds were considered. Comments included, “Different nationalities work here and it’s no longer a problem. When Muslims are fasting, breaks are designed around them. They adjust the rota to childcare needs and are very flexible. We can ask for special permission for longer breaks for overseas staff” and “They are managing different people from different backgrounds, and [registered manager] recognises that not everyone is the same and manages that so there is fairness.”

The provider did not have effective systems of accountability, oversight or governance. Leaders did not act on known risks or performance information, and governance arrangements were ineffective in identifying, addressing or preventing repeated shortfalls in people’s care and safety.

The provider’s governance systems failed to recognise a range of shortfalls in people’s care and the service. This included the lack of monitoring of people’s distressed behaviours, health and welfare as identified in this report. A provider’s representative undertook an audit on 19 March 2026 where they identified shortfalls around recording of the care, the smell of urine on floors and the delay in care being provided or recorded. Although the report showed what needed to be completed, there were no clear actions around this was going to be done or the deadlines for this. All of these concerns remained at this inspection.

In relation to oversight of care notes to ensure staff were recording people’s urine output appropriately the registered manager told us, “I wouldn’t expect nurses to monitor. It would be as and when for a care review, things like that. We have a documentation audit but not care notes audits that I am aware of.” This meant that they were missed opportunities to identify the concerns around skin monitoring not being accurately recorded, health information from partners lacking detail, people sleeping in other people’s rooms and people not having showers.

The leaders had not undertaken regular visits to the service out of hours to ensure people were being kept safe from harm.

Leaders did not always ensure CQC was notified of significant events at the service including police incidents and incidents of safeguarding. After the inspection the provider sent in the notifications that were required,

The provider was unable to provide evidence of an effective system to assess, monitor and improve the quality and safety of the services provided and to ensure they had met the regulatory requirements.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

We found where external professionals had given advice this was not always being followed. For example, as recommended by the Speech and Language Therapist (SaLT), 1 person who was at risk of choking, was trialing have their meals changed from modified to normal foods in the hope this might encourage them to eat more. The SaLT asked for staff to record and monitor how the person was eating for 1 week. There were no records of staff monitoring this and staff were not present with the person whilst they were eating on both days of the visit.

We noted in 1 person’s hospital discharge letter that it was recommended that they were referred to a urology to trial not having a catheter as they kept pulling it out. It was noted in the outcome letter from the health care professional that staff had advised them the person had no concerns with their catheter. As a result the person was discharged by the consultant. However, care notes showed the person continued to have concerns with their catheter. There was no evidence the person’s GP had this information shared with them and no evidence the person had been re-referred to the consultant.

In other areas staff contacted health care professionals in a timely way including the GP, occupational therapist and dietitian. One health professional told us, “They’re always polite. They follow the right processes. “They’re always very engaged and give a good history of the patient.”

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

One relative told us of the management of the service, “It’s a difficult job but I can’t see [registered manager] making sufficient improvements.” Another told us, “Communication. I tell one person and it doesn’t get passed on……They improve and then it goes downhill again.”

Where incidents had occurred, there remained a lack of analysis of these to look for themes and trends. Leaders had not considered incidents where people had sustained skin tears and bruising, which may have as a result of poor moving and handling practices by staff. They had not considered incidents of people walking into other people’s rooms could have been prevented if they reviewed staffing levels and/or how staff were deployed.

There was no detailed analysis of people’s distressed behaviours to understand people’s triggers and to determine whether staff were following the guidance on how best to support people. By systematically reviewing incidents, services can implement changes lead to continuous improvement. This might involve revising protocols, enhancing staff training reduce the likelihood of future incidents. We found this was not taking place.

Leaders missed opportunities to identify recurring risks and share learning more widely within the organisation to prevent similar issues arising. For example, weaknesses in the monitoring of people’s urine output had not been recognised or addressed through internal learning mechanisms.