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Archived: Windmill House Inadequate

Inspection Summary


Overall summary & rating

Inadequate

Updated 18 June 2016

This inspection took place on 26th and 27th November 2016 and was unannounced. This was the first inspection of the service since registration.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. This person was also the nominated individual for the company.

Windmill House provides personal care. At the time of our inspection they provided personal care and support to three people who were the tenants of Windmill House. The staff team did not provide any personal care services to any other people.

We found that the service did not ensure that people were kept safe from harm or abuse. This meant that the service was in breach of breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Safeguarding service users from abuse and improper conduct. This was because not all staff had received training and potential safeguarding incidents had not been referred to the local authority.

You can see what action we told the provider to take at the back of the full version of the report.

The service did not have enough staff hours to deliver care to people who used the service. This was a breach of Regulation 18 (1) Staffing because staffing levels were inadequate to meet assessed needs.

You can see what action we told the provider to take at the back of the full version of the report.

The organisation managed recruitment and disciplinary processes appropriately.

Medicines were being administered appropriately but we recommended that the registered manager completed audits of medicines in the service.

We also recommended that infection control audits were completed.

Staff induction, training and supervision did not meet the needs of the staff team. This meant that the service was in breach of breach of Regulation 18(2) because staff were not being suitably developed in their roles.

You can see what action we told the provider to take at the back of the full version of the report.

Staff were unaware of their responsibilities under the mental Capacity Act 20015. Where people lacked capacity suitable procedures were not put in place to gain consent. The provider was in Breach of Regulation 11: Need for consent.

You can see what action we told the provider to take at the back of the full version of the report.

The staff provided people who used the service with suitable meals but the service did not use nutritional planning to ensure everyone's needs were being met. The provider was in breach of Regualtion14: Meeting nutritional and hydration needs.

You can see what action we told the provider to take at the back of the full version of the report.

We observed staff who were caring and considerate with people who used the service. We judged that a more person centred approach needed to be taken and we recommended that more emphasis be placed on supporting people to be as independent as possible.

All three people who used the service had care plans in place. Some aspects of care and support were not included in the care plans. Plans were not written in a person-centred way. This meant that the provider was in breach of regulation 9: Person-centred care.

You can see what action we told the provider to take at the back of the full version of the report.

Complaints were not always managed appropriately and this meant that the provider was in breach of Regulation 16: Receiving and acting on complaints.

You can see what action we told the provider to take at the back of the full version of the report.

The registered manager was not available and staff were unsure of who was in charge of the service in her absence. Quality monitoring systems were not operating

Inspection areas

Safe

Inadequate

Updated 18 June 2016

The service was not safe.

People were not protected from harm and abuse because safeguarding procedures were not being followed.

There were not enough staff to support the people who used the service.

The quality monitoring of medicines had not been completed.

Effective

Inadequate

Updated 18 June 2016

The service was not always Effective.

Some staff had received no training.

Staff did not understand their responsibilities in relation to the Mental Capacity Act.

Nutritional planning was not in place.

Caring

Requires improvement

Updated 18 June 2016

The service was not always Caring.

We observed kind and considerate care from staff but had evidence that may have indicated that this did not always happen.

Care plans were not written in an easy read format and were not accessible to people in the service.

Independence needed to be promoted in the service.

Responsive

Requires improvement

Updated 18 June 2016

The service was not always responsive.

Care planning failed to meet some of the needs of the people who used the service.

Activities were limited and did not always reflect peoples wishes.

Complaints were not handled appropriately.

Well-led

Inadequate

Updated 18 June 2016

The home was not well led.

Staff were unsure about who led the day to day care delivery in the absence of the registered manager.

Records were unavailable or incomplete.

The service had not monitored or evaluated quality in the service.