Windmill Manor

Updated 18 March 2020

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

Inspection team

The inspection was carried out by three inspectors, a specialist nurse advisor and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Windmill Manor is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we held about the service including feedback shared with CQC and information within statutory notifications. Statutory notifications are reports of events or incidents providers are required by law to tell us about.

We sought feedback from commissioners and placing authorities. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections.

During the inspection

We spoke with seven people, six relatives and three visiting healthcare professionals. We also spoke with the registered manager, the regional director, the clinical development nurse, the chef, two nurses, two senior care staff and three care staff.

We reviewed care plans for seven people and looked at four staff files. We reviewed a variety of documents related to the running of the service including incident records, complaints, meeting minutes and records related to staffing. We looked at a variety of checks and audits as well as information about staff training.

After the inspection

We received email evidence from the provider which we considered when preparing this report.

Updated 18 March 2020

About the service

Windmill Manor is a care home providing personal and nursing care to 50 people with nursing needs, most people living at the service were living with dementia. The service is registered to support up to 60 people. People received care in one purpose-built building with communal areas and outdoor spaces.

People’s experience of using this service and what we found

People, relatives and staff said there were not always enough staff to meet people’s needs. We observed instances where low staffing numbers impacted on people’s care, particularly at mealtimes. There were limited checks in place to monitor staffing and the tool to calculate staffing numbers did not always reflect people’s needs. Records relating to creams and topical medicines were not accurate, we received confirmation of action taken after the inspection to address this.

People said they felt safe with staff and plans were in place to assess and mitigate risks. Medicines were administered to people by trained staff. The home environment was clean and staff were trained in infection control. Background checks had been carried out on new staff to ensure they were suitable for their roles.

Staff worked closely with healthcare professionals to meet people’s needs and we received positive feedback from professionals about staff competence and communication. People liked the food that was prepared for them and their dietary needs were met. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People got on well with staff and we made observations of pleasant caring interactions which showed kindness and compassion from staff. Staff respected people’s privacy and dignity when delivering care and people were encouraged to do tasks themselves to promote their independence.

There was a range of activities at the service which were suited to people’s needs. Care was planned in a personalised way with regular reviews, which people and relatives said they were involved in. People’s wishes and preferences regarding end of life care were documented. People knew how to complain and any complaints had been investigated and responded appropriately.

There was a variety of checks and audits in place and aside from where we found shortfalls in records relating to staffing and creams, audits were effective in identifying and addressing any issues. People and staff had regular meetings to involve them in the service and we saw evidence of work with the community and other organisations to improve people’s care experiences.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 17 May 2017)

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified a breach in relation to staffing numbers. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.