CQC report explained · a nursing home
What the CQC found at Windmill Manor
Rated Inadequate: inspectors found the home performing badly and the CQC has taken enforcement action.
What inspectors found, March 2020
Windmill Manor was rated Requires Improvement because staffing was not always sufficient to keep people safe, although care was often kind and personalised.
This was an unannounced planned inspection on 22 January 2020. Inspectors spoke with people, relatives, staff and visiting healthcare professionals. They reviewed care plans, staff files, staffing records, complaints, incidents, meetings, audits and training records.
The main concern was staffing. Inspectors saw people waiting for help at lunchtime and found that low staffing affected supervision and interaction. In the four weeks before the inspection, 10 people had been found on the floor, including four incidents in communal areas that staff had not witnessed.
The home was rated Good for Effective, Caring and Responsive. People were generally treated kindly, received personalised care, had access to activities and were supported with food, healthcare and communication. Safe and Well-led were rated Requires Improvement because of staffing shortfalls, incomplete records for creams and weaknesses in checking staffing levels and reporting one safeguarding allegation to CQC.
The overall rating fell from Good at the previous inspection, published on 17 May 2017, to Requires Improvement. The provider said it had recruited extra staff for lunchtimes and reviewed its staffing tool after the inspection.
Kind and respectful care
People were treated with kindness and compassion. Staff knew people well and supported their dignity, privacy and independence.
“We observed pleasant caring interactions between people and staff.” from the report
Personalised support
Care plans included people's preferences, histories, communication needs and changing needs. People and relatives were involved in reviews.
“Care plans contained detail for staff about how to provide support to people in a personalised way.” from the report
Good healthcare support
Staff worked with healthcare professionals and followed guidance about people's physical and mental health needs.
“Healthcare professionals gave positive feedback on the care provided.” from the report
Activities and community links
People could take part in a range of activities, with support available seven days a week. The home also had links with local schools and community groups.
“There were staff who took the lead on activities alongside volunteers and this support was available seven days a week.” from the report
Clean environment
Inspectors found the home clean, with regular cleaning and infection control training for staff.
“The home was clean with no malodours.” from the report
Staffing levels
seriousThere were not always enough staff to supervise people and provide help promptly. Inspectors saw two people wait 45 minutes for support to eat at lunchtime.
“There were not always sufficient numbers of staff deployed to safely meet people's needs.” from the report
Falls and supervision
seriousSeveral people were found on the floor, including incidents in communal areas that staff had not witnessed. This created a heightened risk because many people could not use a call bell.
“The frequency of them showed there was a heightened risk to people due to a lack of supervision.” from the report
Creams records
needs fixingRecords did not always show when skin creams had been given. The provider shared plans to improve how these creams were recorded.
“Daily records showed staff had not always documented when these creams had been administered.” from the report
Management checks
needs fixingThe staffing calculation tool did not always reflect people's needs, and there was no documented audit of staffing cover. The provider also had not recently surveyed people and relatives about staffing.
“There were checks and audits in place, but systems had not identified and addressed the shortfalls we found in relation to staffing numbers.” from the report
Late notification to CQC
needs fixingOne allegation of abuse had not been reported to CQC until the inspection, three weeks after it occurred.
“The notification was sent on the day of inspection, which meant it was not submitted in a timely manner.” from the report
- 01What staffing levels are now in place on each floor, especially during meals and when people need two staff for personal care?
- 02How do you now check that the staffing tool reflects each person's current falls, supervision and care needs?
- 03What evidence can you show that the extra lunchtime staff have improved waiting times and supervision?
- 04How are creams and other topical medicines recorded now, and how is this checked?
- 05How do you ensure safeguarding incidents are reported to CQC promptly?
This was an unannounced inspection of the care home, including its premises and care, and inspectors assessed all five CQC key questions. This explanation was written from the published report of 18 March 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.
What inspectors found, May 2017
Rated Good; inspectors found safe, kind and effective care, with further work needed on personalised activities and some care plan details.
This was an unannounced inspection on 19 April 2017. Inspectors spoke with people living in the home, relatives, staff and healthcare professionals. They observed care and reviewed care plans, staff files, medicine records and other documents.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines practice, suitable training, kind care and good access to healthcare.
This inspection followed concerns found in July 2016 about staffing, management checks and notifications to CQC. Inspectors found that action had been taken and the previous breaches and warning notices had been met. They said more work was still needed to keep improving individual activities and some care plan information.
Improved staffing
Inspectors found enough staff on duty and did not see people waiting for support. Staffing and deployment had improved since the previous inspection.
“People were cared for by a sufficient number of staff.” from the report
Kind and dignified care
Staff were attentive, respectful and gentle. They supported people's choices, privacy, independence and relationships.
“People were treated with kindness and attentive care, respect and dignity.” from the report
Safe medicines
Medicine records had no gaps, medicines were stored securely and instructions were in place for medicines given when needed.
“We saw no gaps in the charts which meant people had been given their medicines as they should expect them.” from the report
Good management improvement
The home had acted on the previous inspection findings. Audits and feedback systems were being used to monitor and improve the service.
“We found at this inspection action had been taken and therefore we found the registered provider had met the warning notices and breaches of regulations.” from the report
Some care plan information was unclear
needs fixingInspectors found contradictions and missing information in some care plans. This included information about eating, joining activities and a person's health history.
“We did find however some areas in people's care plans when information appeared contradictory or could be confusing to a staff member who may not know the person as well.” from the report
More personalised activities needed
needs fixingActivities were available, but inspectors said more work was needed to make them meaningful and individual, especially for people who spent a lot of time in their rooms.
“We did however speak with the registered manager about a couple of discrepancies in care plans as well as the need to ensure that work continued on creating new activities and pasttimes, particularly for those who may spend a lot of time in their rooms.” from the report
Ongoing recruitment issue
minorStaffing was sufficient during the inspection, but the registered manager said recruitment was still an ongoing issue and agency staff were used to fill rota gaps.
“The registered manager added that recruitment was an on-going issue and although they were recruiting continually they filled any gaps in the rota with agency staff.” from the report
- 01How do you check that care plans do not contain contradictory or missing information?
- 02How do you record and monitor food and fluid intake for people at risk of malnutrition?
- 03What individual activities are available for people who spend much of their time in their rooms?
- 04How often are agency staff used, and how do you maintain consistency for residents when they are used?
- 05What changes have been made since the April 2017 inspection?
This was an unannounced follow-up inspection covering all five key questions and checking action taken after concerns and breaches found in July 2016. This explanation was written from the published report of 17 May 2017 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 Manor
4 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- March 2020Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 25 February 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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