CQC report explained · a nursing home
What the CQC found at Windmill Lodge Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe and inspectors found detailed risk assessments, suitable staffing levels, safe medicines systems and effective infection control. A few people said staff were sometimes busy and did not always have much time for them.
- Effective?
- Good
- People's care, nutrition and healthcare needs were assessed and reviewed. Some staff had missed refresher training dates, and one mental capacity assessment needed more information about how the decision had been reached.
- Caring?
- Good
- People described staff as kind, polite and respectful. Inspectors saw personalised interactions and found that people were involved in decisions about their care, choices, privacy and independence.
- Responsive?
- Good
- Care plans were person-centred and regularly updated. The home provided activities, communication support and food choices suited to people's needs, and complaints were recorded and acted on.
- Well-led?
- Good
- Inspectors found approachable leadership, supportive staff culture, good partnership working and quality checks that were used to improve care. People and relatives were given opportunities to provide feedback.
What inspectors found, September 2021
Windmill Lodge Care Home was rated Good; inspectors found safe, kind and personalised care, with some training and record-keeping issues to monitor.
Inspectors visited on 4 August 2021. They spoke with 16 people, 17 staff members and seven healthcare professionals. They reviewed care records, staff files, medicines records, complaints, incidents and management checks. They also looked at infection prevention and control.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People told inspectors they felt safe and were treated with kindness, dignity and respect. Risk assessments, medicines systems, care plans and activities were generally well managed.
Inspectors found some staff had missed refresher training dates. One mental capacity assessment did not explain clearly enough how the decision had been reached. The management team said these issues were being addressed and that progress would be checked at the next inspection.
The overall rating had improved from Requires improvement at the last comprehensive inspection, published in May 2019. Safe and Well-led had remained Good since the focused inspection published in August 2020.
Detailed risk planning
Risk assessments covered individual risks and set out steps to keep people safe. Inspectors found that incidents were recorded, acted on and used for learning.
“Staff completed series of person-centred risk assessments for each person who lived in the home.” from the report
Kind and respectful care
People said staff were caring and polite. Inspectors saw staff reassuring people, answering questions patiently and supporting privacy, dignity and independence.
“We observed personalised and kind interactions between staff and people.” from the report
Personalised care
Care plans reflected people's preferences, abilities and wishes. They were reviewed regularly and included support for communication, activities and changing needs.
“Care plans were person-centred, regularly updated, and reflected best practice.” from the report
Strong quality checks
The home used audits and meetings to monitor care, medicines, fire safety and infection control. Inspectors found that actions were followed up and lessons were shared.
“Quality assurance processes in place were robust and monitored appropriately to ensure good care delivery.” from the report
Refresher training
needs fixingSome staff had missed the dates for refresher courses. The management team said training gaps had been identified and addressed, but inspectors planned to check progress.
“However, we saw that some staff had missed the end date for the refresher courses to be completed.” from the report
Mental capacity records
needs fixingOne mental capacity assessment did not include enough information to show how the decision had been reached. The management team agreed to review its processes.
“However, a mental capacity assessment we viewed required more information on how the decision was reached.” from the report
Time for personal attention
minorAlthough inspectors found enough staff to meet care needs, a few people said staff were sometimes busy and did not always have much time for them.
“They don't always have much time for you.” from the report
- 01How are refresher training dates now tracked, and what happens when a member of staff misses one?
- 02How do you check that mental capacity assessments clearly explain how decisions were reached?
- 03How do you make sure staff have enough time to talk with residents and provide personal attention?
- 04What progress has been made since inspectors identified gaps in training and mental capacity records?
- 05How are residents and families involved when care plans and best interest decisions are reviewed?
This was a comprehensive inspection covering all five CQC questions, including infection prevention and control; it checked whether improvements from earlier inspections had been sustained. This explanation was written from the published report of 28 September 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, August 2020
Windmill Lodge Care Home is rated Requires Improvement; inspectors found safe care and stronger leadership, but only Safe and Well-led were inspected.
This was a focused inspection on 6 August 2020. Inspectors spoke with people living in the home and staff, observed care, and checked care plans, risk assessments, medicines records, staffing information and quality checks. They also reviewed infection control arrangements during the COVID-19 pandemic.
The home was rated Good for Safe and Good for Well-led. Inspectors found enough staff, safer medicines management, improved risk assessments, better infection control and stronger systems for learning from incidents. They also found that a new registered manager had made improvements to the environment and the way the home was run.
The overall rating remains Requires Improvement. This is because the inspection only covered Safe and Well-led, while the ratings for the other areas were carried forward from an earlier comprehensive inspection. The home was no longer in breach of the regulations previously identified for staffing and quality monitoring.
Staffing improved
Inspectors found staffing levels met people's needs and staff responded promptly. The home had also reduced its reliance on agency staff.
“Call bell response times were regularly reviewed and checked. We also saw that staff responded to people's needs quickly.” from the report
Medicines were safer
Medicines were managed in line with guidance. Controlled drugs were securely stored and records were properly maintained.
“Medicines were now managed consistently and safely in line with national guidance.” from the report
Better risk management
Care plans contained detailed risk assessments covering areas such as falls, eating and drinking, skin care and behaviours that could cause harm.
“Risk management plans we saw were very detailed and understood by staff we spoke with.” from the report
Improved infection control
The home had arrangements for isolating people returning from hospital and had safety measures for visitors, including checks, protective equipment and cleaned visiting areas.
“The home now managed infection prevention and control well.” from the report
Stronger leadership
Inspectors found a new manager and management team had made improvements across the home. Quality checks were regular and included action plans.
“Quality assurance audits were conducted regularly, with clear action plans to identify and remedy areas for improvement.” from the report
Overall rating remains Requires Improvement
needs fixingAlthough Safe and Well-led improved to Good, the overall rating stayed Requires Improvement because ratings from the earlier comprehensive inspection were still used.
“The overall rating for the service has remained as Requires Improvement.” from the report
Several areas were not checked
minorThis visit did not inspect Effective, Caring or Responsive. Families should ask the home about its current performance in these areas.
“We therefore did not inspect them.” from the report
- 01What are the current ratings and most recent findings for Effective, Caring and Responsive?
- 02What further work is planned to improve the overall rating from Requires Improvement?
- 03How do you check that staffing levels continue to meet people's changing needs?
- 04How are families told about incidents, complaints and lessons learned?
- 05How are infection control and visiting arrangements kept safe as guidance changes?
This was a focused inspection of Safe and Well-led, including infection control; the other key questions were not inspected and their previous ratings were used. This explanation was written from the published report of 26 August 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Windmill Lodge Care Home
5 rated inspections over 6 years: the service has held its Good rating throughout.
- September 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2020Requires improvementstayed Requires improvementSafe: GoodWell-led: Good
- May 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2014Inspected but not rated
- October 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 21 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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