The Windmill Care Home Ltd

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This is the first assessment for this service since the service name change. The provider has remained the same. At our last assessment of this key question we rated this key question good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The service was in breach of legal regulation in relation to consent to care and treatment and nutrition and hydration.

This service scored 25 (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 make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

Pre-admission assessments of people’s needs were not thorough and did not establish whether the service could safely meet their needs. A member of staff told us the service was not suitable for, “a lot” of the people living there due to their complex care needs.

One person told us they did not meet anyone from the service for a pre-admission assessment before they moved there.

People’s needs were not regularly assessed or reviewed, and care records were not accurate or reflective of people's care needs.This meant people were at risk of receiving care that was not effective, inappropriate or unsafe. For example, two risk assessments for 1 person described their mobility needs differently. One stated they would use a walking frame for mobilising and another described they used a wheelchair for all transfers and no longer walked independently. A second person’s care records also contained conflicting information about their mobility. One care record stated they were a falls risk and another described them as immobile. This meant staff did not have clear information about how to support the person with this need.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

The electronic care planning system in place had nationally recognised assessment tools to determine people’s risk in relation to nutrition and hydration and tissue viability, for example. However, these were not being used. The Malnutrition Universal Screening Tool (MUST) is a screening tool to determine a person’s risk of malnutrition. Whilst we could see the MUST score in people’s care records, it was unclear how this was assessed and how often the score was calculated.

We found this to be the same for the Waterlow score, which is a screening tool to determine a person’s risk of developing a pressure ulcer.These tools help to determine how at risk a person is of malnutrition or developing pressure ulcers. If this risk is not determined correctly, then the appropriate measures cannot be put in place. For example, we saw people had lost significant amounts of weight and there was poor monitoring of their food and fluid intake.

The provider did not work well across teams and services to support people.

We found staff and health and social care professionals did not consistently have accurate information about people’s care needs which would allow them to deliver care in line with people’s individual needs.

Where people’s care needs changed, they were not referred for specialist advice. When professionals gave advice and made recommendations, this was not followed. For example, a health professional had advised for a person to be given a minced and moist diet, instead, it was recorded in their care records and documentation kept in the kitchen as they should be given a soft and bite sized diet. This put them at risk of choking. One healthcare professional we spoke with told us they sometimes had to “prompt” staff for more information about a person.

The provider did not support people to manage their health and wellbeing, so people could not maximise their independence, choice and control. Staff did not support people to live healthier lives, or where possible, reduce their future needs for care and support.

Whilst some people and their relatives reported they were supported with their health and wellbeing, we found some people had lost significant amounts of weight and referrals had not been made to healthcare professionals, despite people showing monthly decreases in their weight.

People were also not referred for specialist advice when there were changes to their health. For example, we saw there was a significant delay in referring a person who had been described as sounding chesty. This increased the risk of this individual receiving medical support in a timely manner.

We saw from a resident’s survey that some people had stated they had not been offered chiropody services since living at the service.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

People’s care plans were not always regularly reviewed. Where they were reviewed, they failed to update people’s care records to reflect their current needs. For example, 1 person’s care records stated they would walk into other people’s rooms. However, elsewhere in their records it described a deterioration in their mobility and were no longer mobile and dependent on staff for all transfers. This meant staff did not have correct information to monitor and support this individual’s needs.

We had serious concerns about the amount of weight some people had lost and found there was no monitoring of people’s food and fluid intake. Daily care records did not always specify how much people consumed. This demonstrated a lack of effective monitoring of risks to people’s health.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment.

The provider failed to adhere to the Mental Capacity Act 2025 (MCA). This had not been applied to ensure people’s rights had been consistently upheld. We saw some people’s consent care plans documented they ‘may’ lack capacity to make decisions due to a diagnosis of dementia. This did not reflect the requirement under the MCA to presume capacity unless established otherwise, nor were capacity assessments decision specific. Where decisions were to be made in people’s best interests, records were not explicit as to who had been consulted, such as, next of kin or GP. They also did not state if those consulted held legal authority to do so, for example via a Lasting Power of Attorney for Health and Welfare.