Windmill Lodge

Updated 8 March 2024

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 Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by 2 inspectors, 2 medicines inspectors and a specialist advisor.

Service and service type

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

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. An interim manager was in place until a new manager who would apply to be registered with the CQC, was recruited.

Notice of inspection

The first day of the inspection was unannounced. The second and third days of the inspection were announced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection including information from the public. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 5 people who used the service about their experience of the care provided, in addition we spoke with 6 relatives. We spoke with 16 members of staff including the interim manager, 3 members of the senior management team, 1 qualified nurse, 7 care staff, one cook, a member of the day centre staff, a well-being co-ordinator and 1 member of the administration team responsible for recruitment. We also spoke with the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We spent time in each area of the home that was in use, carrying out observations and speaking with people, staff and relatives. We reviewed a range of documentation relating to the management of the home and 4 staff personnel records. During the inspection process we continued to review records sent to us by the interim manager and also reviewed parts of 14 people’s electronic care records using a remote log in to a secure system.

Updated 8 March 2024

About the service

Windmill Lodge is registered to provide nursing and residential care for up to 100 people. People may require support with residential care needs and or/ nursing care needs and may be living with dementia. It is a purpose built home which is divided into four separate areas. At the time of the inspection 43 people were receiving care and support at the home.

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

Staff did not always follow agreed processes to report incidents to senior management. Safeguarding notifications were not always made to local safeguarding authorities. Processes to help ensure suitable staff were employed to work at the home were in place and the home was clean and hygienic. People's medicines were managed safely. We recommend the provider reviews the recording of patch applications to ensure they are applied as per manufacturer’s guidelines.

People were supported by staff who had not always had training to enable them to meet people’s needs. Staff were effectively deployed. Nutritional risk assessments were carried out and care plans recorded the needs of people in relation to their nutrition and hydration needs. People were referred to external health professionals if this was required.

People's privacy and dignity was not always protected. One communal area of the home did not have window and a door covering. The environment did not always support the needs of people who lived with dementia. We have made a recommendation about this. People were supported by staff who were kind and patient in their approach and people told us they could make decisions about their care.

Checks and audits were carried out but these did not always drive improvement. The interim manager and nominated individual said when things could have been done differently, they would act openly and transparently. Staff said they felt the interim manager was making positive changes and they were committed to making improvements.

People could take part in a programme of activities if they wished to do so, and care records contained person centred information about people’s histories and personal routines. People’s communication needs were considered and documented to support people to communicate their needs and wishes. There was a complaints policy to support people to raise concerns or make complaints.

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

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

Rating at last inspection

This service was registered with us on 26 April 2023 and this is the first inspection.

Why we inspected

The inspection was prompted in part due to concerns received about such as the admissions process, medicines, staffing and staff training. A decision was made for us to inspect and examine those risks.

You can see what action we have asked the provider to take at the end of this full report.

The provider increased staffing and ensured staff completed training during the inspection process. This minimised associated risks.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring and well-led sections of the full report.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement and Recommendations

We have identified breaches in relation to safeguarding people who may be vulnerable, staff training, dignity, and good governance. We have made recommendations about the safe management of medicines, and signage within the home.

Follow up

We will request an action plan from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.