The Windmill Care Home Ltd

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.

This is the first assessment for this service since the service name change. The provider has remained the same. 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 atthe service, safeguarding people from abuse, staffing and fit and proper persons employed.

This service scored 34 (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.

Recording and analysis of falls and incidents was poor. Records in relation to these were not always fully completed and were not always reviewed in a timely manner. This meant additional measures to mitigate future occurrences were missed.

Analysis of falls did not identify there were a high number of unwitnessed falls and what may have contributed to this.

Our review of records identified a high number of incidents involving behaviour that challenged. No learning took place from these incidents. Therefore, measures were not implemented to mitigate the risk of future incidents.

Staff told us they did not receive updates with lessons learned from incidents. This did not demonstrate a culture of learning to drive improvement.

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.

Concerns in relation to people’s health and well-being were not always identified. Where concerns had been identified in relation to people’s needs, timely referrals were not made, or in some cases, not made at all. For example, the daily care records for one person showed they were often found in urine-soaked clothes, and some entries stated they were found in a soiled bed. We did not see any referrals to an incontinence specialist.

People’s safety was not monitored, and some people’s care records showed an escalation of incidents in relation to behaviour that challenges, this included towards other people living in the service and staff. The escalation of incidents had not been identified, placing people at risk of harm.

People’s care records contained conflicting or incorrect information about their care needs. For example, in a care plan for one person it stated they required repositioning to prevent the development of pressure ulcers, while another care plan for this person stated repositioning was not being monitored. The inconsistencies meant an inaccurate account of their care needs could be handed over to other professionals or hospital staff should they be admitted.

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. The provider did not share concerns quickly and appropriately.

Although relatives told us they felt their family members were safe, with one saying, “Yes, absolutely,” we found serious concerns in relation to safeguarding. A review of records showed safeguarding incidents had not been identified as safeguarding incidents and therefore were not reported to CQC as notifiable incidents, or to the local authority safeguarding team.

People’s right to live safely was not upheld. For example, we reviewed records of incidents where people living in the service could show sexually disinhibited behaviours towards other people. Action was not taken to ensure this risk was managed and people were protected from harm.

Records of incidents showed staff did not take appropriate action where people were showing behaviour that challenged. The recorded action staff took were to leave the person rather than observe or redirect. This placed people at risk of avoidable harm.

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.

People were not safe because potential risks had not been identified or acted on. We saw from 1 person’s daily care notes they had developed an open wound. No medical advice had been sought in relation to this, and their associated care plans and risk assessments had not been updated to reflect their current needs in relation to skin integrity.

Weight records showed several people had lost significant amounts of weight. Risks related to people’s health through weight loss had not been assessed. Referrals had not been made to relevant healthcare professionals such as the GP or a dietician. Without detailed and accurate information, staff were unable to ensure they could provide safe care that met people's needs and mitigated risks.

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

Whilst concerns within the environment had been documented. Timely remedial action had not been taken. For example, management walkarounds had noted the handle on an external fire escape route was broken. The provider fixed this after CQC raised concerns about the lack of action.

Windows requiring repair and a leak in the roof continued to be identified at these walkarounds for 3 consecutive months without remedial action.

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.

Although we received mainly good feedbackfrom people and their relatives about staffing levels, others we spoke with had concerns. A person we spoke with said, “We need more staff, they’re always busy.”

A staff member told us, “There’s not enough staff on duty, that’s a common complaint amongst staff.”

A healthcare professional described the staffing situation as, “Overworked and understaffed.” They added they can be left waiting at the front door and again once in the service while a staff member is found to escort them to the person they were visiting.

The dependency tool the provider used to calculate how many hours of care people required was ineffective. It did not take into consideration the complexity of the care needs some people were living with. Calculations of dependency to determine staffing levels were not undertaken regularly and was only assessed 4 times between August 2023 and April 2026.

The provider failed to meet the expectations set out within their own training policy. Considering the needs of people and the seriousness of some of the incidents recorded at the service, less than half of the staff had completed training in positive behaviour support, sexual harassment awareness, managing continence and nutrition and hydration. Only 24% of staff had completed classroom-based practical moving and handling training.

Recruitment of staff was not always safe and risk assessments for staff with previous convictions were not robust.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The overall cleanliness at the service was good and free from malodours. There was a dedicated team of domestic staff and there were good practices in the laundry room and there was a one-way system to ensure clean laundry was not contaminated by dirty laundry.

We also found the kitchen to be in good order with regular cleaning in place as well as stock rotation and labelling of foods once opened.

There was a good supply of personal protective equipment for staff such as aprons and gloves. We observed staff wearing these where appropriate.

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

Covert administration requires authorisation from a GP to confirm that it is safe, clinically appropriate, and supported by clear instructions for how the medicines should be given. Reviews were not completed when medicines administered covertly were changed, this increased the risk of people receiving medication that was not effective.

Controlled drugs were not always signed for as being administered and the stock check of these drugs failed to identify the missing signatures. We also found missing signatures on medicine administration record (MAR) charts and where people were prescribed topical medicines. Therefore, we could not be assured that people had received their medication as prescribed.

One person was prescribed insulin, and the normal blood glucose range for them had not been recorded. It is important to know this range as it can vary for individuals and ensures they receive the correct amount of insulin.

Protocols for medicines taken on a when required basis (PRN) lacked detail and did not always document the correct administration instructions as stated on the corresponding MAR chart supplied by the dispensing pharmacy. We found PRN protocols lacked detail about what medicines were for and when it should be given, for example, specific signs and symptoms or behaviours to look for. Therefore, we were not assured people were receiving as required medication when they needed them.