Archived: Windmill House

Updated 18 June 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection of the location took place on 26th and 27th November 2015 and was unannounced.

On Thursday 26th November 2015 the visit was conducted in the early evening by an inspection manager and an adult social care inspector. The visit the next day was conducted by the adult social care inspector. We were unable to visit the registered office of the provider at this inspection.

We met the three people who used the service and we spoke with three relatives prior to the inspection and after the visit. We met with five staff and spoke to other members of the team by telephone. We also spoke with the director of the company. The registered manager (who is also the nominated individual for the company) was unavailable during and after our inspection.

We looked at three care files, records of money held on behalf of people who used the service and the medicines the staff supported them with.

We looked at staff files in the location. We saw some records of training and some supervision notes.

We looked at a range of records kept in the location but did not access any documents that were not held at Windmill House. Some information was sent to us after the visits.

Updated 18 June 2016

This inspection took place on 26th and 27th November 2016 and was unannounced. This was the first inspection of the service since registration.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. This person was also the nominated individual for the company.

Windmill House provides personal care. At the time of our inspection they provided personal care and support to three people who were the tenants of Windmill House. The staff team did not provide any personal care services to any other people.

We found that the service did not ensure that people were kept safe from harm or abuse. This meant that the service was in breach of breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Safeguarding service users from abuse and improper conduct. This was because not all staff had received training and potential safeguarding incidents had not been referred to the local authority.

You can see what action we told the provider to take at the back of the full version of the report.

The service did not have enough staff hours to deliver care to people who used the service. This was a breach of Regulation 18 (1) Staffing because staffing levels were inadequate to meet assessed needs.

You can see what action we told the provider to take at the back of the full version of the report.

The organisation managed recruitment and disciplinary processes appropriately.

Medicines were being administered appropriately but we recommended that the registered manager completed audits of medicines in the service.

We also recommended that infection control audits were completed.

Staff induction, training and supervision did not meet the needs of the staff team. This meant that the service was in breach of breach of Regulation 18(2) because staff were not being suitably developed in their roles.

You can see what action we told the provider to take at the back of the full version of the report.

Staff were unaware of their responsibilities under the mental Capacity Act 20015. Where people lacked capacity suitable procedures were not put in place to gain consent. The provider was in Breach of Regulation 11: Need for consent.

You can see what action we told the provider to take at the back of the full version of the report.

The staff provided people who used the service with suitable meals but the service did not use nutritional planning to ensure everyone's needs were being met. The provider was in breach of Regualtion14: Meeting nutritional and hydration needs.

You can see what action we told the provider to take at the back of the full version of the report.

We observed staff who were caring and considerate with people who used the service. We judged that a more person centred approach needed to be taken and we recommended that more emphasis be placed on supporting people to be as independent as possible.

All three people who used the service had care plans in place. Some aspects of care and support were not included in the care plans. Plans were not written in a person-centred way. This meant that the provider was in breach of regulation 9: Person-centred care.

You can see what action we told the provider to take at the back of the full version of the report.

Complaints were not always managed appropriately and this meant that the provider was in breach of Regulation 16: Receiving and acting on complaints.

You can see what action we told the provider to take at the back of the full version of the report.

The registered manager was not available and staff were unsure of who was in charge of the service in her absence. Quality monitoring systems were not operating effectively in the service. This meant that the provider was in breach of Regulation 17: Good governance.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.