This was an unannounced inspection that took place on 17 December 2018.

Windmill House is a care home that provides accommodation and personal care for a maximum of 59 older people. People in care homes receive accommodation and nursing or personal care as 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 is provided in one purpose built building on two floors. The bedrooms are single occupancy with ensuite bathrooms. There are pleasant internal and external communal areas for people and their visitors to use. At the time of the inspection there were 57 people using the service. Most of these people were living with dementia.

The service had a registered manager in place. 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.

At the last inspection this service was rated as good. At this inspection we found that improvements had been made and the service was now rated outstanding.

The care that people received was individualised and very person-centred. The registered manager was an inspiring leader of an enthusiastic staff team committed to providing the best care for people. Care focussed on supporting people’s independence and promoting dignity and respect. Relatives were encouraged to take an active part on the life of the home which supported people’s relationships. There was a whole team approach to the service which included staff, people and their relatives. Spending time with residents was a focus for the service and they had introduced a “happy hour” each day as a time when everyone should take time out to have a drink and spend time with people.

People’s social and life history shaped the care that people received as well as the appearance and design of the building. There was active engagement with the local community so that people were supported to attend events in the local community as well as inviting people from the local community to take part in the homes events. There was an excellent range of activities reflecting the diverse preferences and needs of individuals in the home. Activities were planned three months in advance and ensured that people who did not like groups or people who spent most time in their rooms were also able to participate. Staff knew people’s work histories and used these to match people to appropriate activities.

The registered manager supported a strong leadership team. The provider supported the high quality of care through a specialist dementia team as well as assisting the service with resources to promote dignity in care. People and relatives spoke very highly of all of the managers. The service had a marketing strategy to develop further their links with the local community, and a business plan to focus on improving the service and learning from best practice. People were encouraged to be involved in the development of the service through resident meetings as well as participating in staff recruitment. Feedback from people was incorporated in meaningful ways and directly impacted on the opportunities provided by the service. Staff were appointed as champions of particular areas such as team building, meal times, or slings, which provided opportunities for staff to develop leadership skills as well as enhancing the care that people received. Equality and diversity was embedded in the service not just for people using the service but also through the staff team.

People felt safe in the service. Risks were monitored, assessed and managed in a positive way to promote people’s independence. The service was fully staffed and staffing levels ensured that there were always staff availab

Windmill House provides accommodation and personal care for up to 59 people, some of whom were living with dementia. There are pleasant external and internal communal areas for people and their visitors to use.

This unannounced inspection took place on 18 February 2016. There were 56 people receiving care at that time.

The service had a registered manager in place. 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.

Staff were only employed after the provider had carried out comprehensive and satisfactory pre-employment checks. Staff were well trained and supported by their managers. There were sufficient staff to meet people’s assessed needs.

Systems were in place to ensure people’s safety was effectively managed. Staff were aware of the procedures for reporting concerns and of how to protect people from harm.

People received their prescribed medicines appropriately and medicines were stored safely. People’s health, care and nutritional needs were effectively met. People were provided with a balanced diet and staff were aware of people’s dietary needs.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and report on what we find. We found that there were formal systems in place to assess people’s capacity for decision making and applications had been made to the authorising agencies for people who needed these safeguards. Staff respected people choices and staff were aware of the key legal requirements of the MCA and DoLS.

People received care and support from staff who were kind, caring, patient and respectful to the people they were caring for. People and their relatives had opportunities to comment on the service provided and people were involved in every day decisions about their care.

People were encouraged and supported to stay active and to develop and maintain hobbies and interests. A varied ranged of activities and events for people to participate in were on offer.

Care records were detailed and provided staff with sufficient guidance to provide consistent care to each person. Changes to people’s care was kept under review to ensure the change was effective.

The registered manager was supported by a senior staff team , care workers, and ancillary staff. The service was well run and staff, including the registered manager, were approachable. People and relatives were encouraged to provide feedback on the service in various ways both formally and informally. People’s views were listened to and acted on. The service had an effective quality assurance system that was used to drive and sustain improvement.

A single inspector for adult social care carried out this inspection. The focus of the inspection was to answer the five key questions; is the service safe, effective, caring, responsive and well-led?

Before this inspcetion we had received some concerns regarding the staffing levels in the home and also practices regarding the dispensing of medications. Therefore we have inspected these areas at this visit and found that the measures put into place by the provider have now addressed these issues of concern. The measures put into place are described in the following report.

Below is a summary of what we found. The summary describes what people using the service, relatives and staff told us, what we observed and the records we looked at. If you want to see the evidence that supports our summary please read the full report.

This is a summary of what we found:

Is the service safe?

Records we looked at showed us that risk assessments were completed where a risk had been identified. Measures were described and in place to reduce or eliminate such risks. Requirements under the Mental Capacity Act 2005 were appropriately in place as were deprivation of liberty safeguards (DoLS), we saw that family members were also included in discussions at this time.

Staff confirmed that they had completed regular training and we saw a list of dates when the staff refresher training was due to be updated. This showed that people were supported by members of staff who knew how to provide support in a safe and appropriate way.

Records showed that equipment such as hoists had been regularly serviced and checks had been completed on fire extinguishers. This supported the safety of people who lived at the service, as well as the safety of visitors and staff.

Is the service effective?

Our observations showed us that people who lived at the service were relaxed and confident when they discussed matters with members of staff. Staff took action when they saw anyone who appeared to be in need of support.

Our discussions with staff at this time and our review of documents showed us that nutrition was monitored by staff. They took note of how much each person ate at meal times. Alternative options were offered if a person did not want the choices available on the menu. Regular checks on people's weight supported the early detection of any problems.

Is the service caring?

Our observations showed us that people living in the service were treated with respect at all times. Discussions with members of staff showed us that they knew the routines that people had chosen and were aware of their care and support needs.

We saw that people were dressed cleanly and appropriately for the weather on the day of our inspection, this showed that people’s support needs had been carried out. We saw that staff spoke with respect and in an appropriate manner when they provided support or care to people in the home.

Is the service responsive?

We saw that people's individual physical needs were being met. People were gently encouraged to decide what they wanted to eat at lunch time. We observed the lunch time meal and saw this was a calm and relaxed time. People were able to choose where they ate their meals and people’s choices were supported.

Staff did not rush anyone and they allowed time for the individual to fully understand the choices that were being offered to them. This showed us that staff supported and involved people who lived at the service.

Is the service well led?

Quality assurance systems were in place and regular quality audits were completed for all areas of the service. We saw records that clearly documented the observations and subsequent actions that had been completed when any improvements were needed.

We assessed compliance with Outcome 9 Medicine Management to follow up on the findings of our inspection during October 2013 when we found and raised concerns relating to how the service managed people’s medicines.

During this inspection we noted overall improvement in the way medicines were managed and recorded. Records showed that people received their medicines as intended by prescribers. Managers regularly monitored and audited medicines and their records. We found written information about people’s medicines had also improved to enable staff to safely administer them.

Each person had an individual care record. This included assessments of individual needs and care plans stating as to how these needs should be met by staff. This meant that people’s care and welfare needs were recorded in detail and their care plans showed that they were being met in line with people’s assessed needs.

The records seen and our observations of individual care practices showed us that people were protected from the risks of inadequate nutrition and dehydration.

The records seen showed us that all the equipment used by the service had been maintained and serviced in accordance with the provider’s policy and procedures. This demonstrated to us that the people using this service were protected from the risks of unsafe or unsuitable equipment.

Staff were able to give us appropriate examples of the care and support that they provided for the people who were using this service. This meant that people were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

We saw examples of care record reviews, infection control and twice weekly medication audits having been carried out by senior staff. We noted that where concerns had been identified, actions to address these had been taken. This showed us that the provider had an effective system to regularly assess and monitor the quality of service that people received.

We inspected this service to assess compliance with Outcome 9 Medicines Management because we were recently notified of an incident where information about a person’s medicines was not correctly transcribed leading to them being administered a medicine that was no longer prescribed. During our inspection we noted minor gaps in record-keeping about the administration of people’s medicines. We found that there were inconsistencies and gaps in information for staff to refer to about the administration of people’s medicines. This could lead to further errors placing the health and welfare of people living at the service at risk. We also noted there to be the potential for error during medicine administration rounds because members of staff conducting the rounds were frequently distracted by demands to undertake other tasks.

We noted there were appropriate arrangements for the storage of medicines, however, medicines requiring refrigeration were not always being stored within the accepted temperature range.

Most people living in the home were unable to tell us clearly what they felt about their care because they were living with dementia. We did receive comments indicating that people enjoyed their food. One described the main meal they had chosen as "...very tasty." One person said that they thought someone had cleaned their room for them. Another was "...happy..." living at Windmill House.

Because many people found it difficult to express their views we spent time observing the care and support that staff offered, on both floors of the home. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. We observed that staff were patient and respectful of the people they were caring for. However, we noted that the deployment of staff on the ground floor resulted in a less 'organised' approach to mealtime and a less positive experience for people than it had been on the first floor.

We found improvements in the way people's care and welfare was maintained, in cleanliness, protection from abuse and in staffing. We noted that the home was not full so that, although they were busy, staff were not as stretched as we saw at our last inspection.

Two regular visitors said that they felt the staff were caring in their approach to people. It was also raised with us that things had improved since the manager had returned to the home on a full time basis.

Many people in the home were not able to speak with us about their experiences. For this reason we observed how they were being supported. Some people told us that they were happy with the staff and their care. They said the food was 'lovely'.

We observed that staff treated people with respect and tried to engage them in conversation. They took time to explain what they were doing. However, they struggled to provide the support that was required to maintain people's health, welfare and social or recreational needs because of staffing levels. Despite this, staff maintained a calm and reassuring approach with people.

Staff were clear that they had an obligation to report anything that might be abusive or concerning, but not clear about the safeguarding process, where they could find information and who - other than the management team - they should contact.

People who were able to tell us verbally about their care described the staff as caring and kind. We were told that, "The staff are all very good. They are around when I need someone."

We saw people being gently encouraged with their mobility and reminded about routines and what was happening next.

We found improvements had been made to the way people's needs were assessed and reviewed. Guidance for staff about how to meet them had improved and staff spoken with had a good understanding of the needs of people living with dementia.

Because most people were not able to tell us verbally what they thought about standards of care in the home, we looked and listened to how people were being supported. We used a tool called the "Short Observational Framework for Inspection" (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who were unable to clearly express their views about their care.

We found that people were treated with respect and that their right to privacy was upheld. Staff encouraged or assisted people to drink sufficient fluids. This was important as we visited on a very hot day. Our observations in the lounge area showed that staff responded appropriately to resolve situations when people became agitated or anxious.

Three people were able to tell us that they felt the food was very good and that there was plenty of it. They felt that staff were good and that there was always something to do.

Three relatives said that staff responded quickly to call bells and always treated people politely. Two of them told us that there were usually activities in the morning and that there was always something different going on to keep people entertained and occupied.