Windlesham Manor

Updated 26 May 2021

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.

We received information of concern about infection control and prevention measures at this service. This was a targeted inspection looking at the infection control and prevention measures the provider has in place.

This inspection took place on 15 April 2021 and was unannounced.

Updated 26 May 2021

This inspection took place on 22 and 30 August 2017 and was unannounced.

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.