Windlesham Manor

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Responsive – this means we looked for evidence that the provider met people’s needs. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people’s needs were met through good organisation and delivery.

This service scored 79 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.The vision and values of the home were clearly communicated and notices displaying the homes culture and ethos are displayed for all to see. There was a team-based ideology created by a member of staff thinking of the staff’s motto “we welcome, we respect, we care” and this has been adopted by all to demonstrate the core values that were held by the service, and they had worked to achieve.The home had informative brochures and a website showing the history of the building. The registered manager told us they were open to trying different things that may make the home a better place. They said, “I want it to be warm, comfortable and relaxed.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. The registered manager was experienced, and proactive in maintaining their own professional development. The registered manager had undertaken a counselling qualification to enable them to provide additional support to people, their relatives and staff. We observed the registered manager interacting with people and staff in a respectful and good-humoured manner. The staff structure shared responsibilities such as on call, and leadership roles. Team leaders supervised care staff and organised allocation of duties and were able to provide cover when the registered manager was absent. The registered manager recognised the support staff needed to be able to work at a continual level of good practice and made themself readily available should staff require their time. Staff told us, “Manager is approachable and does listen and is open to suggestions.” Staff explained they had asked for a door to be fitted with a keypad as residents often walked into the staff area. This was quickly organised by the registered manager and showed he was responsive to concerns raised by staff. The maintenance staff told us they had a good working relationship with the registered manager and owners, and were provided with all the tools they needed to carry out their job

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.Staff told us they were confident in speaking up and a whistleblowing policy was in place. Staff had opportunities to give their views through staff meetings, supervision meetings and feedback questionnaires. Staff were heard at shift handover explaining changing needs to other staff and discussing routines and giving their opinions on current issues within the home. The registered manager acted with honesty and promoted transparency within the home. Staff were encouraged to speak up, and the registered manager operated an open-door policy. They were always accessible to staff being on-call when not actively working in the home.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The care team included both male and female staff of varying age and experience. Many had worked at the service for a long time, and the registered manager told us they valued loyalty and commitment to the home. Staff were employed from different nationalities and backgrounds creating a diverse and varied workforce. Equality and diversity policies were in place, and the registered manager promoted a fair and inclusive workplace, with some flexibility in working arrangements balanced to suit both staff and people’s needs. For example, additional staff worked for a short time first thing in the morning to support with breakfast and medication administration. This enabled medicines to be given promptly and increased numbers of staff available to support people in the morning. Staff told us they did not mind working as it was a short amount of time rather than the whole shift.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. The registered manager and leadership team were committed to ensuring people received a high level of care. There was a clear staff structure within the home and staff understood their roles and accountability according to seniority. There were systems in place to identify and manage current and future risks. Audits were carried out and any findings acted upon.Reporting any concerns or incidents to others was done via secure channels maintaining people’s confidentiality, and management and senior staff worked together to share these responsibilities. The registered manager told us they had developed a good relationship with the local authority safeguarding team and has contacted them for advice and support when needed.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.Staff arranged support from partner services and continued people’s regular routine health checks with dentists, opticians and chiropodists. Professionals who regularly visited the home told us staff were well informed and knew people’s needs. People had a regular weekend visit from a young person completing their Duke of Edinburgh Award who sat and spent time with them. People were supported to interact with the local community and had attended events and activities at local venues, for example the community centre. Information was readily available to people about the events and activities offered in the local community such as the dementia café and local shows.

The provider had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.The registered manager told us that he had a good working relationship with the provider. There had been new equipment recently, for example a new call bell system had been ordered, and the cook told us about improvements in the kitchen. The registered manager was exploring university courses to further develop his own learning in dementia support and managerial processes, and the provider had agreed to fund this for them. The registered manager kept informed of new guidance from Local Authority and CQC, they also attended manager forums. Learning and training for all was encouraged, with one professional saying, “The home is willing to learn and open to training opportunities shared to the team and I have often seen them at training that I have recommended.” The registered manager was proactive with championing new ideas to benefit the home and people living there. Installation of a communication system was arranged and Windlesham Manor had been the first home in the UK to implement it. The system supports people to be independent in their communications as they do not require staff assistance to use it. The system allows people to make calls to individual rooms, the registered manager or families and friends, and enables a video call promoting social interactions at a time of the person’s own choosing. This had supported families to be involved with medical reviews, and supported people to have direct communication with the registered manager. People were able to view more of nature as the registered manager had introduced numerous bird boxes to the garden, and people had decorated them as an activity. People could watch nesting chicks grow and develop to adults as there is a camera in one box which people could access via the TV in the communal lounge.