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 Requires Improvement. At this assessment the rating has changed to Good. This meant people were safe and protected from avoidable harm.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a positive learning culture within the service, based on openness and honesty. The management team listened to any concerns or issues raised by staff, people and relatives, and systems were in place to ensure these were investigated and lessons learnt. Lessons learnt were discussed with staff in regular staff meetings. The registered manager completed an analysis of incidents at the service, which they used to make improvements. For example, they evidenced where an analysis of increased skin tears was attributed to the way in which some staff worked, this resulted in immediate action being taken to mitigate further risk. People and their relatives were encouraged and supported to raise concerns and knew who to contact if they had any issues. One relative told us, “I know who to raise things with and I feel they would deal with it correctly.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored. They made sure there was continuity of care, including when people moved between different services. Timely and appropriate referrals were made to healthcare professionals. The registered manager maintained relationships with local GPs. Allied healthcare professionals visited the home to support people, as well as to provide bespoke training for staff, which enhanced their ability to support the varied needs of people.

The provider shared concerns quickly and appropriately and worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. People were supported by staff who were aware of the signs of abuse and knew how to report safeguarding concerns, “We need to be observant and make sure if a person looks depressed or is angry and acting out of character then it is important to let the nurse know. We would then see if there is a pattern to the changes in behaviour and see if there is reason.” Staff told us they were confident the management team would address any concerns regarding people’s safety and well-being and make the required referrals to the local authority. Relatives told us, “[Person] is absolutely safe. There are excellent and safe processes for entering and exiting the home. The staff always seem to know [person’s] whereabouts which I find reassuring.” A healthcare professional told us, ‘I feel staff are able to recognise safeguarding and follow agreed plans.’

The provider did not always work well with people to understand and manage risks. We found that whilst risk assessments contained details of the risk, some lacked detail specific to the person for how staff should support them. For example, ‘needs regular laxatives, nurses to monitor for continence.’ There was no guidance on what constituted ‘regular’, or where to record any monitoring. We noticed that some people’s repositioning charts were not always filled in. Nurses we spoke with acknowledged this and said that whilst charts were not always completed as they should be, they were confident that carers repositioned people as advised. We spoke with the registered manager who was also aware of this matter. They said a new electronic recording and monitoring system was due to be installed 4 weeks following this assessment. We subsequently confirmed with the provider that the electronic system was installed. One of the functions will be to flag up any missed episodes of care which can then be addressed in real time. However, staff were able to tell us about people and the risks associated with their care. They told us how they supported them safely. This included pressure area management, safe mobility and what to do when people became distressed. Relatives told us they were confident staff understood people’s risks, “Very much so. [Person] had an episode two months after moving in, and the staff were amazing and really understood what was going on, they took great care of [person].”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. There were safety certificates in place for safety checks of equipment including hoists, slings, wheelchairs as well as regular recalibration of weighing scales. The environment was kept safe by regular checks and maintenance, which were monitored by a maintenance team and the provider. Regular fire safety checks and evacuation tests were carried out. A fire risk assessment was completed in November 2024. No significant actions were required, and all of the recommendations were actioned.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. People told us, “There always seem to be plenty of staff around” and “I have never found [person] needing or wanting something and a carer not being available.” However, some people commented that there were fewer staff around at the weekend, “At weekends there are less staff. Gaining entry at weekends can sometimes take a while,” and “Weekdays staffing levels are fine but at weekends it feels likes it is less.” The registered manager told us they regularly reviewed staffing levels according to people’s changing needs, and generally ensured there were more staff on duty than the assessed hours indicated. They said the number of staff on duty was consistent across the whole week, with no reduction at weekends. Staff told us there were enough staff on duty, “We are not under pressure when we do our work, not rushing all the time”, and “We have enough time to sit and chat with the residents, do crosswords with them. I like this part of my work.” People told us staff were trained to provide safe and effective care, “Yes, I’m amazed about all they know. They are proud of their work,” and “Yes I believe so, they definitely know how to lift me safely.” Staff told us training they received and the supervision offered by senior members of staff enabled them to do their job to the best of their abilities. They said, “We have lots of on-going training and get reminded when it is due. When I started, I shadowed an experienced member of staff before I was ready to work on my own.” Staff were recruited safely as the provider undertook identity checks before they started work. Checks included eligibility to work in the UK, references from previous employers, Disclosure and Barring Service (DBS) checks and current nurse registration checks.

The provider did not always assess or manage the risk of infection. The environments of the ground and first floors differed greatly. The ground floor was recently refurbished, and looked clean, bright and well maintained. However, there was a very strong malodour on the first floor, especially in the dining/lounge area, and some upholstery on the chairs was heavily stained. There was a small kitchen area in a part of the lounge, which had broken cupboards and damaged work surfaces and showed signs of long term neglect. Relatives told us, “Sometimes there is a strong smell of urine and I do think that is something they could address,” and “I feel that upstairs needs a good upgrade. Downstairs has a coffee area but upstairs doesn’t have anything like that.” References to the ground floor included, “The bedrooms and the public areas are spotless. I see staff wearing gloves and aprons.” The registered manager told us the first floor refurbishment was scheduled for March 2025, but agreed that because of this, basic maintenance on the first floor was neglected. However, a healthcare professional told us a recent contagious infection at the home was ‘well managed and monitored and effective plans put into place.’

Medicines were managed safely and there were systems and processes in place to promote this. Regular audits were undertaken, and action taken to address any concerns. This meant any errors or learning opportunities were identified in a timely manner. We found people's medicines were received, stored and administered safely and their medicine administration records (MAR) were completed. A healthcare professional told us, “I recently observed 2 nurses who were competent in the administration of medication. Things appeared to be more organised, because they had a regular team of nurses and were relying less on agency staff.” Staff told us they had received medicines training and their competency to safely administer medicines was regularly re-assessed. People told us they received their medicines on time. Where medicines were given covertly, the provider ensured the correct process was followed in line with people’s best interest. The management team completed medicines audits regularly to identify any errors or poor practice.