The Windmill Care Home Ltd

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.

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 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 good governance at the service.

This service scored 29 (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.

The provider had a Statement of Purpose which set out the core vision for the service, and it outlined the values and outcomes they wanted to achieve for people who lived at the service. This document was misleading in parts and stated there were 4 lounges, where there were only 2. An open plan lounge with 3 televisions in was classed as 3 lounges in the Statement of Purpose. People told us they felt unable to sit in there due to the amount of noise.

We found the vision set out in the Statement of Purpose did not translate to practice. For example, the service described 1 of their aims was people could expect a thorough assessment of their needs and systematic and continuous planning of their care. Feedback from people and records we reviewed confirmed this was not the case.

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 identified multiple breaches of the regulations and significant concerns at the service. The provider had failed to identify and act on these prior to our assessment. The nominated individual was not regularly in the service and did not step in to provide leadership and support when the previous registered manager resigned and a member of staff told us how the provider did not provide enough support to them during this change.

We received mixed feedback from people and relatives regarding the leadership at the service. One relative told us, “There is a very open-door policy and [it’s] easy to contact staff and managers.” Whilst another person told us the provider was not in the service often and a member of staff confirmed this.

People did not feel they could speak up and that their voice would be heard.

Whilst the provider sourced feedback from people, their relatives and staff through surveys, analysis of these did not identify key themes. For example, responses from people living in the service indicated there were a lack of activities in the service. No action had been taken to address this and feedback received as part of this assessment showed this was still an area for improvement.

Whilst some feedback we received was positive with one member of staff saying, “The office is always open if I want to talk.” Other feedback given was less positive and when staff did speak up, they did not feel listened to.

One person told us, “The staff are nice but they’re always short staffed. I’ve had this argument with [1 of the provider’s directors] many times, but [they] don’t listen.” One staff member said, “In care, you should be able to raise issues. I don’t agree with their values. We don’t have support and not allowed to talk about anything.”

There were no meetings for people to attend to share their view on the service. Many people living in the service were living with dementia and there were no alternative ways to gather regular feedback from them. There were also no meetings for relatives, who could advocate for their loved ones to speak up on their behalf about the service being delivered.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

We were told by a member of care staff, care staff and domestic staff were treated less favourably than kitchen staff and this caused some discord.

There was limited engagement from the provider, they were not a regular presence in the service and staff meetings and supervisions did not happen regularly. This meant staff did not have a regularly opportunity to raise concerns or provide feedback about the service.

Many staff were working without having completed the required training set by the provider to enable them to work to a high standard. For example, less than half of the staff had completed training in hand hygiene. This meant staff did not always have the appropriate skills to support people living at the service.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider failed to implement effective audits and quality assurance processes to ensure the care people received was safe, effective and responsive to their needs.

The provider did not have a whole service audit to monitor the quality and safety of service being delivered. Where audits were completed, we identified significant shortfalls in relation to the quality and effectiveness of them as they failed to identify the serious and widespread concerns found at this assessment. For example, health and safety audits failed to identify unsecured items which posed a risk to people. We requested the provider implemented additional safety measures in response to our findings.

The provider failed to adhere to their own policies and procedures. For example, the provider did not follow their policy in relation to care planning. We found people’s care plans were not person centred and did not reflect their most current care needs. This was not reflective of the processes detailed in the provider’s care planning policy.

Furthermore, the provider failed to notify CQC and other relevant stakeholders of reportable incidents in line with the Regulations.

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

People’s relatives told us staff contacted healthcare professionals where necessary. However, we found people’s care records were not reflective of their current needs, and therefore staff did not have appropriate information to hand, and to relay to healthcare professionals.

Where there were changes to people’s needs, referrals were either not made or were delayed. This included appropriate referrals to support residents with wound management and weight loss. For example, we saw from daily care notes 1 person had developed redness to their skin on an area vulnerable to pressure ulcers, and then it was later documented they had an open wound. There was no evidence a referral to the relevant healthcare professionals had been made. In addition to this, records show people’s intake of food and fluid were not documented to ascertain if there was a link to the weight loss. Where advice had been sought for additional support, this was not always correctly documented. For example, the speech and language therapy team recommended a person’s food to be prepared in a certain way to avoid choking, but this was recorded to be prepared at a different consistency to that advised.

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.

The provider did not use the data they had to learn from incidents or drive improvement within the service. For example, most falls were unwitnessed, as identified by the provider’s analysis. However, further action had not been taken to understand why people were having so many unwitnessed falls, and what measures could be put in place to reduce this.

Where people had sustained a serious injury through a fall, no further analysis was conducted to identify a root cause. Furthermore, learning from incidents was not recorded or shared formally with staff either in meetings or supervisions.

Training records highlighted poor training compliance, but there was nothing to show this had been escalated and an improvement plan in place.

We were shown a messaging application where information was shared with staff on their personal phones. Whilst people’s full names had not been used, personal information about people was being shared via a social media messaging service on personal devices. This went against the provider’s social media policy. We raised our concerns about this, and the messaging group was deleted.