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 Requires Improvement. At this assessment the rating has changed to Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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 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 registered manager and staff understood the provider’s vision and values to provide good quality care, with supporting policies and procedures. The registered manager demonstrated a positive approach to continuously develop the home, which was shared by staff who told us, “We all have good ideas which we are encouraged to put forward, I think this home will continue to flourish” and “I feel I contribute to team meetings and am listened to. I can make suggestions for change. The manager and clinical lead are approachable. This is a really good company to work for, they look after us.”

Management had daily updates from heads of departments and key information was communicated with the staff team.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. The registered manager was committed and understood their legal responsibilities. There was a clear management structure that ensured staff had effective support and guidance at all times. The provider maintained oversight of the care home with regular visits, audits and accessing the electronic system remotely. People and relatives told us they felt the service was run by capable leaders and they were visible and responsive. One relative told us, “It was the most traumatic time for me to put [person] into a home and they made it so incredibly easy. They were all so kind and made it bearable for us as a family” and “Yes its delightfully managed. It feels like a family friendly place.” Staff spoke positively of the leadership team, “The manager is very approachable and has changed a few things since their arrival.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People, staff and their relatives were provided with opportunities to speak up during care reviews, phone calls, supervisions, meetings and using the whistle-blowing procedure. A staff member said, “We have a speak up champion and the company encourages us to speak up, that is why I feel safe and protected to work here.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The registered manager ensured equality of opportunity and experience for the workforce, for example, recognised when staff needed additional support and responded appropriately. Staff felt valued, supported and described being treated fairly and equally with regards to their protected characteristics.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Whilst there was a structured approach to quality assurance, including audits and checks, these did not identify the shortfalls already highlighted in this report which included a lack of decision-specific detail in risks assessments and care plans. The provider has since provided assurances that the move to an electronic record keeping system is now complete and all care plans, risk assessments and capacity assessments were updated. In addition, the complete refurbishment of the first floor was underway.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. An allied healthcare professional told us, ‘I believe the home is working in partnership with others. I have attended or been invited to networking events at the home, to further this.'

The provider focused on continuous learning, innovation and improvement across the organisation. Lessons learnt from accidents, incidents and complaints were reviewed and shared with the staff team. Staff told us these were shared during handovers and team meetings.