Windlesham Manor

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.The registered manager told us they operated an open-door policy and supported a positive culture of transparency within the home. Staff told us, “People’s safety is well managed here. We learn from mistakes. For example, putting out crash mats when people might have falls.” Staff felt confident in the reporting procedures and that they would be listened to by the registered manager. Systems were in place to identify risks. Themes and trends were analysed and then acted on in a timely manner to minimise future harm, for example falls monitoring procedures and protocols. There had been a high number of recent falls within the home, but the circumstances of these were being looked at and risks mitigated. Correct procedures for reporting and recording identified risks were followed.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.People had a hospital passport which is a summary of care and communication needs that can be printed out and taken with someone whenever they move or visit a new health or care environment. Staff worked with various professionals to ensure people's care needs were met when they moved in. Staff worked with district nurses to ensure people who needed it received specialist support with managing their skin integrity.Prior to admission people and families were involved in the pre-assessment and information gathering process and were able to personalise the room before people’s arrival to help people settle and feel more at ease.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.Care needs were identified and risk assessments were completed prior to people being admitted. The provider understood their responsibilities to report any concerns and made referrals to appropriate partners in a timely manner. Safeguarding information was kept in a file in the ground floor office, easily accessible for staff to reference and know what to do. A team leader told us, “I am confident that my team would know what to do” and a member of staff said, “If I thought it wasn’t safe of course, I would speak”.The Mental Capacity Act 2005 (MCA) provides a legal framework for making decisions on behalf of people who may lack the mental capacity to do so for themselves. Deprivation of Liberty Safeguards, (DoLS), were in place and had been applied for in the correct manner. DoLS ensure that people who lack mental capacity to make the specific decision about receiving care and treatment are protected and any restrictions on their freedom are lawful and in their best interests. When required, people’s capacity to make a particular decision had been assessed, in accordance with the MCA, and best interest meetings had been held involving the GP and family members. For example, to discuss giving medicine covertly for someone who was not taking their essential medicines. Records had been updated to reflect this information, so all staff were aware. People told us they felt safe and looked after.

The provider always worked well with people to fully understand and manage risks by thinking holistically. Staff provided care that fully met people’s needs and was safe, supportive and enabled people to do the things that mattered to them.People’s independence and choice were supported with thorough risk assessments. One person had requested to have specific electrical items in their room, and this had been put in place for them following discussion and review. The person’s ability to use the items safely was regularly reviewed. They had been given a key to lock their room so no other people could access the items when they were not there. People were supported to take positive risks to maintain independence. Some people did their own ironing with support from staff.One person told us that they had requested to move rooms after doing a fire drill and finding it hard to get downstairs; this had been organised for them straight away. They told us, “I do feel safe here and that’s important. That move made me feel safer.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.The service was clean and tidy with no visible hazards to people living there. Maintenance records were kept up to date, for example water, gas and electrical appliance testing. All policies had been reviewed and updated for all maintenance areas. Cleaning products were stored securely. People had access to equipment to safely support them to mobilise and transfer between areas, and this was regularly checked and maintained. Fire exits were clear from obstruction and fire safety equipment was in place through the home. A grab file was available containing people’s personal emergency evacuation plans, (PEEPs), and there had been regular fire drills carried out for staff and residents. Staff told us, “Fire alarm tests are regular and (we had) a recent mock evacuation.”

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.The registered manager determined the staffing levels according to people’s needs and was flexible in their approach. All staff had access to training and development of skills via a digital training platform and face to face courses provided by trained staff. The registered manager had a teaching qualification and used this to develop workshops for staff to attend to provide a more interactive approach within the care team. This was particularly useful for new staff starting at the home. Staff were recruited safely and on starting employment staff completed an induction booklet. Agency staff were sometimes used to ensure the staffing numbers remained at the required level for safe delivery of care, and regular staff had been requested to help keep continuity. A member of staff told us “We do use agency staff but only to cover holidays. We use the same few, so they know the home.” If there were new agency staff, then they worked alongside regular staff until they were familiar with people, or they had attended prior to their shift to familiarise themselves with the home. Staff were able to view people’s current information via individual handsets that linked to the care plan system, and they could enter updates and daily reports throughout the shift. People told us, “‘I like it very much; the place and the staff are all lovely.” A relative told us, “I quite often visit at a weekend and always plenty of staff on and to hand if needed.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The home was clean and tidy. On entering there was a digital temperature recognition face scanner in the hallway so all visitors could check for any raised temperature before moving into the main areas of the building. The registered manager had all relevant policies in place and daily cleaning schedules were completed by housekeeping staff. Cleaning products were stored securely. There were ample supplies of personal protective equipment, (PPE), with safe disposal areas throughout the home which were easily accessible to staff. Food was prepared in accordance with the appropriate standards, and the service had been rated the highest score of 5 from their last food standards inspection. Protocols were in place for the containment and management of any outbreak of infection, with clear directions of how to escalate and receive support from specialist healthcare teams.

Medicines were safely stored however record keeping for medicines was not always up to date. For example, 3 bottles of paracetamol solution had no dates of opening on them. Staff said it would normally be written on in black marker pen, so it was easily seen. Stock levels for some medicines were not always accurate. Staff understood how this had occurred and what to do to prevent it in the future. Medication Administration Record sheets (MARs) were clear, with important information highlighted for all staff to notice. However, there were no homely remedy MARs sheets in use for when homely medicines were administered. Homely remedies are medicines that can be bought over the counter and used when required. The registered manager said he would look to resolve this immediately. Medicine ordering processes worked well and medicines were stored safely. PRN protocols, instructions for medicines that are not required all the time, were in place. Medicine policies and procedures were easily accessible to staff. Care plans detailed people’s specific medicine needs, for example a person with Parkinson’s disease had information emphasising the need for time critical medicines each day. Families were included in reviews and a relative told us “Yes, we actually had a meeting last Friday about a change of medications, so we are kept up to date with any changes” A person also managed their own medicines and told us, “Every month staff gives me a new month’s supply.” The team leader confirmed this routine and said they always involve the person each month and do regular audits to ensure they are taking medicines as directed.