Windmill Care Centre

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. 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 regulations in relation to safe care and treatment, safeguarding and safe recruitment of staff.

This service scored 38 (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. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.
One person was assessed as at risk of ingesting non-food items from the floor, surfaces, or objects due to their eating behaviour. Despite this, we found artificial flowers in their bathroom, a potential ingestion hazard, without any evidence this environmental risk had been assessed or mitigated in line with their needs. In addition, this individual’s choking risk assessment categorised them as being at 'very high risk', with their care plan clearly requiring one-to-one supervision at all times to prevent avoidable harm. However, we found daily records showed they were regularly left to eat unsupervised in their room and were frequently observed walking unaccompanied in corridors and entering other people’s rooms without staff presence. These failings indicated that known and serious risks were not effectively monitored or managed, and care was not delivered in a person-centred or safe manner. The provider did not ensure consistent supervision was provided to support this person with their high-risk level of needs. This also did not demonstrate the provider used these known risks as part of a proactive learning culture to ensure a culture of safety and learning was implemented for continuous improvement.
 

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety.
The provider did not always demonstrate they ensured continuity of care and safety during transitions. One professional told us, “There was no end-of-life care plan for a newly admitted resident who was prescribed just in case medication.” One relative told us, “When she first arrived she was given a room on the upper floor because they thought she had dementia, but she doesn’t and then they moved her”. The provider did not demonstrate care and support was planned and organised with people, together with partners and communities in ways that ensured continuity. This also did not ensure the views of people who use services, partners and staff were always listened to and taken into account.

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.
The provider failed to demonstrate people were safeguarded from the risk of harm and abuse. Despite repeated incidents of people being visited in their rooms without their consent and exposed to sexualised behaviour, the provider did not evidence these events were always investigated without delay, reported and learnt from to drive improvement in people’s safety. The provider did not evidence a proactive learning culture; effective monitoring systems and appropriate risk management systems were in place to ensure sexual safety of people was maintained. There was also no evidence that those affected were adequately supported or safeguarded following these incidents, and risk assessments lacked timely updates and appropriate interventions. This represented a serious systemic failure to identify, respond to, and manage sexual safety risks within the service. The impact of this meant it placed people at immediate and ongoing risk of sexual abuse, severely compromised their safety and dignity, and constituted a fundamental failure in safeguarding and a duty of care.

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.
The provider did not ensure care and treatment was provided in a safe way for all people using the service. One person had a known and significant history of self-harm and suicidal ideation, including a documented risk of ligature, which is whereby anything such as a cord or other material, that could be used for the purpose of hanging or strangulation. During our site visit we identified unsecure ligature risks within the environment had not been adequately assessed or mitigated to protect this person from serious harm. Although a ligature risk assessment had been completed, there was no evidence to confirm the assessor’s competence in identifying and managing all ligature risks. The care plan and associated risk assessments lacked specific detail regarding the person's triggers for distress and failed to provide staff with clear, actionable steps to de-escalate or prevent high-risk behaviours. Furthermore, photographic evidence submitted by the provider after the inspection confirmed that not all ligature anchor points had been appropriately addressed, leaving the individual exposed to an ongoing level of danger and risk of significant harm.
People with known risk of choking were not always supported to safely manage and mitigate this risk of avoidable harm. One person required staff to ensure they are sat upright to prevent risk of aspiration and choking. We observed this person lying down with a plate of food on their chest. No staff were present to ensure the known risk of choking was safely managed during their mealtime. This did not demonstrate the provider ensured the known risks to people were safely monitored and managed to ensure they did not experience risk of avoidable harm.

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.

The provider failed to ensure the safe management of water temperatures and the control of legionella risks. At the time of our site visit, a dedicated maintenance team was not in place. This meant staff were completing water temperature checks. However, staff were not adequately trained or assessed as competent to carry out water temperature testing, or legionella testing to safely monitor water systems. In addition, hot and cold-water outlet temperatures for people’s showers were not consistently maintained within safe ranges, and there was no evidence of effective follow-up when higher readings were recorded. This meant there was a scalding risk to vulnerable individuals. Furthermore, flushing records for infrequently used outlets and vacant rooms, were incomplete, which further compounding the risk. These failures demonstrate a lack of oversight, staff competence, and environmental safety governance. The absence of robust water safety protocols placed people at immediate and ongoing risk of serious harm, including scalding and potential exposure to legionella bacteria, which can lead to life-threatening illnesses such as Legionnaires’ disease.
People felt the environment required refurbishing. One person told us “This room really needs re-furbishing – cleaning it won’t make any difference”. Another person told us, “They clean OK but the carpet is really old – it needs replacing”.

The provider did not always 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 always work together well to provide safe care that met people’s individual needs.
The registered manager did not operate effective and robust recruitment procedures to ensure they employed suitable staff. We found discrepancies with gathering information of full employment history and unexplained gaps, health questionnaires, evidence from previous employments related to health and social care regarding staff conduct and verifying the reasons for leaving. We asked the provider for further evidence on the missing information; however, this was not all provided. By failing to obtain all required recruitment information before staff started work, the provider put people at risk of being supported by unsuitable staff.

We reviewed staff training and competency assessments. The provider acknowledged that while a specific, formal training programme for nursing staff to become designated competency assessors was not yet in place, they recognised the need for consistency and quality in assessment and were exploring ways to strengthen and formalise this process. At present, assessments were carried out by care staff the provider called, designated ‘Daymakers’. This approach, however, raised concerns about the accuracy and reliability of competency checks. We saw evidence of spot checks and staff supervisions, but these were not consistently carried out at regular intervals to ensure close performance monitoring and ongoing staff development. Some competency assessment forms were incomplete or lacked detail.
During our review of daily care records, we identified examples of staff performing clinical tasks without documented evidence of appropriate training or competence. For instance, one person using the service had a catheter in place, and staff were supporting them with catheter bag changes. However, there was no record on the training matrix or elsewhere to evidence this staff had received training in catheter care or had been assessed as competent to carry out this task. This meant people were at risk of receiving inconsistent, unsafe and poor-quality care, and staff did not always receive the support they needed to deliver safe care.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.
We observed personal protective equipment (PPE) was not always readily available for staff to use when supporting people. For example, one nurse was looking for PPE aprons before they could support someone with eating, this caused a delay for the person to have their lunch. We observed another occasion where staff did not use utensils or gloves to pour cooked food when serving dinner. This did not always demonstrate best practice for hygiene and cleanliness.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning their medicines support.

During our site visit we found some expired medicines were in use, we raised this to staff. Although the provider discarded these immediately, this did not demonstrate there was always effective oversight of medicines on premises to ensure people were not at risk of having expired medicine administered. The provider did not ensure labels were always applied to medicine bottles to clearly specify when they were opened which would ensure safe management and oversight of medicine. Some items which should have been stored in a clinical fridge to ensure optimisation and best practice, such as eye drops were not stored appropriately.
We found people’s ‘when required’ (PRN) medicine protocols were not always person centred and detailed according to their individual needs. For example, one person was prescribed with a PRN sedative medicine. Their care plan did not clearly outline how and when to use the medicine, any identifiable triggers and supportive coping techniques to use before administering. This meant people were at risk of being administered PRN medicine ineffectively and not in accordance with their individual needs.
Some people received medicine covertly. We found their covert administration of medicine guidance noted how to prepare medicine; however it was unclear how this was monitored to ensure preparation was correct, and people took full doses of medicine if the covert process was used. Care plans reviews noted covert administration would remain for people if needed. However, people’s daily notes did not demonstrate they were consistently refusing medicine. This did not demonstrate people’s needs with medicines were assessed appropriately and people received their medicine safely according to their individual needs.