We carried out a review of the data available to us about Windlesham Manor on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Windlesham Manor, you can give feedback on this service.
We found the following examples of good practice.
The service had a visitor booking system in place to ensure areas could be kept clean between visits. A dedicated visiting room had been created with screens and seating which was distanced. During good weather people had the option to meet visitors outside in the garden. The manager was preparing for government updates about visits to care homes and was planning to change arrangements according to new guidelines.
The manager had increased communication links with people's family and friends during the COVID-19 pandemic restrictions. Regular emails from the service shared information and pictures about people's activity and menu options, celebrations and wellbeing. People had access to equipment for video calls and telephone calls, staff supported these when required.
Changes had been made to how staff, visitors and people moved in and around the building. The entrance had been changed and a one way system was in place in some parts. Staff and visitors had access to a sensor controlled wash basin, automatic temperature monitoring and personal protective equipment.
During the recent COVID-19 outbreak zones had been created with designated staff allocated to each zone, this reduced the movement of staff through the building. People were supported to isolate in their room, individual activities and social contact with staff was increased to help minimise isolation. New scrubs were provided for staff to wear, these were laundered on site. The manager was proud of the way staff had worked together as a team during the pandemic and believed the staff team was stronger as a result.
Cleaning regimes had been changed to increase frequency and thoroughness around the building. Cleanliness was regularly audited by the manager. PPE was observed to be appropriately worn and there were good supplies in place.
The manager reported having good links to GP and healthcare professionals with visits or video calls in place when people needed them.
Windlesham Manor is registered to provide personal care and accommodation for up to 40 people. There were 37 people using the service during our inspection who were living with a range of care needs. These included dementia and mobility support.
Windlesham Manor is a large detached Edwardian country house, set in landscaped gardens in the village of Crowborough, within Ashdown Forest. The home is located in a semi-rural area where there are some shops, a church, a bus and a train service.
A registered manager was in post. A registered manager is a person who has registered with the care Quality Commission to manage the service. 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.
Windlesham Manor was last inspected in December 2016, when it was rated as: ‘Requires improvement’ overall with a rating of ‘Inadequate’ in the question: ‘Is the service safe?’ We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 at that inspection and issued requirement actions and warning notices. The breaches of regulation related to risks around maintenance, the safe storage of medicines, safe employment checks, premises being maintained and cleaned, the monitoring and recording of falls, premises being suitable to people’s needs, the provision of food and hydration to meets people’s needs, care plans reflecting peoples assessed needs, and operating systems to monitor the quality of the service. The provider sent us an action plan to tell us how they would address these breaches by July 2017. At this inspection we also made a recommendation. You can see the recommendation in the main body of the report.
People were kept safe at Windlesham Manor. Staff told us they understood the importance of people's safety and knew how to report any concerns. Risks to people's health, safety and wellbeing had been assessed and plans were in place which instructed staff how to minimise any identified risks.
There were suitable arrangements in place for the safe storage and administration of people’s medicines. And people received their medicines when they needed them by trained staff.
There were sufficient numbers of staff deployed to meet people’s needs. Some call bells took a long time to answer but by the end of our inspection the registered manager had implemented an audit and had improved response times. The registered provider had effective and safe recruitment procedures in place and staff told us that they had the training they needed to carry out their roles.
People had access to sufficient quantities of food and drink to remain healthy and told us they liked the food. People saw their GP or other health and care professionals as and when they needed to.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.
Staff treated people dignity and respect. Staff were knowledgeable about people's likes, dislikes, preferences and care needs. People’s privacy was respected by staff who valued people’s unique characters.
Staff were kind and caring: good interactions were seen throughout our inspection, such as staff sitting and talking with people as equals and treating them with dignity and respect. People could have visits from family and friends whenever they wanted.
People did not consistently receive a person centred service. Some people had diagnoses that were not addressed in their care plans or guidelines that were not fully recorded in plans.
There was a range of activities on offer to people to maintain their interests and keep people occupied. Complaints were being used as a tool to improve services.
There was an open, transparent culture and good communication within the staff team. The registered manager took an active role within the service and led by example. There were clear lines of accountability and staff were clear about their roles and responsibilities. The provider had systems in place to assess and audit the quality of the service and utilised both internal and external auditing tools.
The registered manager had notified us of events that had occurred within the service so that we could have awareness and oversight of these to ensure that appropriate actions had been taken.
Windlesham Manor is a family run care home in Crowborough which provides residential care and support for up to forty older people. Some were older people living with dementia; some had mobility difficulties and sensory impairments. Some people received their care in bed. Accommodation is arranged over two floors. There is a passenger lift for access between floors. There were 36 people living at the service on the day of our inspection.
The service 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.
People told us they liked living at Windlesham Manor. They felt safe and well looked after.
Effective recruitment procedures were not in place to ensure that potential staff employed were of good character and had the skills and experience needed to carry out their roles.
Medicines were not well managed. Medicines had not been stored and recorded appropriately.
The provider and registered manager did not have suitable control measures in place to minimise the risk of Legionnaires disease.
Risks to people’s safety and wellbeing were not always managed effectively to make sure they were protected from harm. Risk assessments had not always been reviewed and updated when people’s health needs changed.
People’s care plans were not complete and were not updated to ensure that their care and support needs were clear and their preferences were known. The service had an electronic care planning system. The staff at the service recorded most of their care and support electronically using the system.
The decoration of the home did not follow good practice guidelines for supporting people who live with dementia.
The provider and registered manager had failed to ensure food met people’s assessed needs and preferences and to ensure that nutrition and hydration met people’s wellbeing. Kitchen staff had not been notified when people’s dietary needs had changed. People had choices of food at each meal time. People were offered more food if they wanted it and people that did not want to eat what had been cooked were offered alternatives. People with specialist diets had been catered for.
Staff knew and understood how to protect people from abuse and harm and keep them safe. The home had a safeguarding policy which was out of date. We made a recommendation about this.
The service had not followed good practice guidance to ensure that new staff received a comprehensive induction and staff supervisions had not always followed the provider’s policy. We made a recommendation about this.
There were no policies and procedures in place in relation to the Mental Capacity Act 2005. Staff had received training in relation to the Mental Capacity Act. We made a recommendation about this.
The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Deprivation of Liberty Safeguards (DoLS) applications had been made to the local authority and had been approved.
People were supported and helped to maintain their health and to access health services when they needed them.
Staff were cheerful, kind and patient in their approach and had a good rapport with people. The atmosphere in the service was calm and relaxed. Staff treated people with dignity and respect.
People were supported to maintain their relationships with people who mattered to them. Relatives and visitors were welcomed at the service at any reasonable time and were complimentary about the care their family member’s received.
People and their relatives knew who to talk to if they were unhappy about the service.
Complaints had been dealt with effectively in line with the complaints policy. The complaints procedure did not evidence who people should talk to if they were not happy with the complaint response, which should include the local authority and Local Government Ombudsman. We made a recommendation about this.
People had opportunities to provide feedback about the service they received. There was no evidence that anything discussed was acted upon to show that people had been listened to.
Relatives and staff told us that the home was well run. Staff were positive about the support they received from the registered manager. They felt they could raise concerns and they would be listened to.
Communication between staff within the home was good. They were made aware of significant events and any changes in people’s behaviour. Handovers between staff going off shift and those coming on shift took place to make sure all staff were kept up to date.
Staff showed us that they understood the vision and values of the organisation; we observed practice to show that staff had embedded this into their work.
We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.