Windmill House

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 inadequate. 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 service now had a strong, motivated leadership team who were continuing to drive changes and improvement within the culture of the service and staff team and were observed to lead by example. Staff worked collaboratively with leaders to achieve consistent care outcomes for people. Our findings were reinforced by the feedback we received. People were familiar with the registered manager and felt able to speak with them openly as needed. Relatives told us, “We cannot fault the management of the service, it is well run, we would recommend it to others.”

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.

We received consistently positive feedback from staff, people and relatives regarding the leadership of the current registered manager. The registered manager’s care and compassion both for people and their relatives, as well as for the staff team was reflected in our findings and the feedback we received. People spoke fondly of the registered manager, and how welcome they felt when they moved into the service. The registered manager recognised the need for staff to be rewarded when making positive contributions to the service and had introduced staff member of the month awards. Staff respected the registered manager, and the values they instilled within the service.

The provider fostered a positive culture where staff, people and relatives felt they could speak up and their voice would be heard.

From feedback we received, and our observations during the inspection process, the leadership team valued, acknowledged and acted upon feedback they received to drive improvement. Changes within the service and staff team were evidenced through a more open and transparent culture. Staff no longer feared if they made a mistake and felt able to speak with the registered manager without fear of reprisals and fully supported to address any concerns or individual performance.

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.

Staff told us they felt recognised for their individual skills and attributes they contributed to the wider staff team and the care provided. We observed respectful, kind and compassionate relationships between, people, relatives and staff. The service was integrated within the wider community, with many external projects and activity groups regularly meeting within the service. Staff and leaders respected people’s individual protected characteristics, and their equality, diversity and human rights were recognised and upheld.

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.

Whilst overall, we found the service to have made considerable improvements to return to compliance with the regulations, there remained some aspects of governance and provider level oversight that continued to need further improvements and review. We liaised with the provider’s representatives as part of the inspection process, and received assurances regarding the ongoing measures and oversight the provider will continue to have to ensure these shortfalls are addressed.

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.

We observed and received positive feedback regarding improved standards of communication between the service and external professionals, as well as relatives, which was felt to have improved approaches to collaborative working. Staff and leaders recognised the value of working in partnership with people and external health and social care professionals to achieve positive care outcomes for people. The service supported people to integrate within the local community, as well as welcoming community groups and events into the service. We received praise for the mother and baby group that regularly spent time at the service, and how much people enjoyed the community integrated activities available. One relative told us, “With the mother and baby group, the whole atmosphere lifts, also young people garden with people and multiple care homes participate in an online singing group.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The overall level of improvement and return to compliance with the regulations following our last inspection demonstrated a clear commitment to learn, improve and respond to the enforcement action taken by CQC. This in turn ensured people received the improved levels of care they were entitled to. We observed evidence of strong leadership with clear plans around how the service wished to continue to improve and embed ongoing changes.