Inspection on 01/11/05 for Windlesham Manor

This inspection was carried out on 1st November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Windlesham Manor 19/02/07

Windlesham Manor 03/05/05

Windlesham Manor 09/01/05

Windlesham Manor 07/09/04

Windlesham Manor 27/06/02

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Windlesham Manor Hurtis Hill Crowborough East Sussex TN6 3AA Lead Inspector Elaine Green Announced Inspection 1st November 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Windlesham Manor DS0000021291.V251999.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Windlesham Manor DS0000021291.V251999.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Windlesham Manor Address Hurtis Hill Crowborough East Sussex TN6 3AA Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01892 652470 01892 652470 Mr Simon Carey Mrs Susan Carey Mrs Yvonne Peskett Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Windlesham Manor DS0000021291.V251999.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of residents to be accommodated will be forty (40) The residents will be aged sixty five (65) or over on admission Date of last inspection 3rd May 2005 Brief Description of the Service: Windlesham Manor is a care home providing personal care and accommodation for up to 40 older people with low to medium dependency needs. The registered providers are Mr S & Mrs S Carey who have owned the home since 1982. The home is located on the outskirts of Crowborough, adjacent to Crowborough Beacon Golf Course. There are local services and facilities in the town, which is about one mile away. The house, which is a listed building, is a large extended two-storey country property. It stands in its own grounds that are laid with paths so that service users can walk in the gardens. The majority of bedrooms are well in excess of the recommended minimum standard size. All have en-suite facilities. There are two passenger lifts to the first floor plus a chair lift on one small flight of stairs. On the ground floor there are two lounges and a large dining room, a conservatory is being constructed, which will increase the communal space available for residents. Windlesham Manor DS0000021291.V251999.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Announced Inspection took place on the 1st November 2005 between 10am and 4pm. As part of the Inspection service users and their relatives were given the opportunity to complete comment cards and return them to the Inspector prior to the Inspection. The registered Manager of the home also completed a Pre Inspection questionnaire this is mainly to gather information regarding the number of service users resident in the home, staffing levels, health and safety, policies and procedures and any other changes that have taken place since the last Inspection. Discussions took place with the Registered Manager and Deputy of the home regarding the day-to-day running of the home. The Inspector also had a tour of the building, joined service users for lunch and discussed with service users what it was like to live in the home. A range of documents, policies, procedures and other records were examined including 4 service users’ care plans and 3 recruitment files. What the service does well: What has improved since the last inspection? Since the last Inspection in May the staff application forms have been amended to include a more detailed background of job applicants e.g. health enquiry and full employment history. Windlesham Manor DS0000021291.V251999.R01.S.doc Version 5.0 Page 6 Steps have been taken to meet the requirements that were made by the Department of Environmental Health in respect of replacing the kitchen floor and this work is on going. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Windlesham Manor DS0000021291.V251999.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Windlesham Manor DS0000021291.V251999.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These Standards were not Inspected. EVIDENCE: Windlesham Manor DS0000021291.V251999.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8. The care planning systems are adequate. Service users health care needs are met. EVIDENCE: Five service users care plans were examined. They included the information and guidance required by staff to support the service users in their daily living. Information is based on risk assessments and had been reviewed on a regular basis. It is required that service users or their relatives are involved in writing of care plans and that they sign the plan accordingly. One relative commented “I am very happy with my relatives care and I’m sure that they are. There is nothing I would change.” Records examined confirmed that health care has been provided to service users on a regular basis and service users confirmed that they always see the doctor or nurse in the privacy of their own rooms. Records also show evidence of multidisciplinary working on a regular basis. Referrals are made to the appropriate health care professionals when required. The manager explained that if they feel that the home can no longer meet the needs of a service user then they undertake a reassessment of their needs and make referrals as required. Documentary evidence examined confirmed this to be the case. Windlesham Manor DS0000021291.V251999.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14,15. Service users are supported to enjoy and autonomous lifestyle. The activities provided by the home are appropriate and meaningful. The arrangements for the provision of food at meal times are good. EVIDENCE: Through discussions with service users, the Manager and by the examination of daily records, it is evident that a range of activities are available to service users. These activities include a knitting circle, a gardening club, quizzes, and trips out, music, exercise classes etc. service users stated that they were happy with the current level of activities and the range on offer. Service users choose whether or not to join in these activities and are involved in discussions with the management re their preferences in such issues as the proposed new lay out of the garden etc. service users stated that they are encouraged to continue with hobbies and interests after they have moved in to the home. The Inspector joined service users in the dining room for lunch. The food was served from a Bane Marie, it was hot, well presented and made from fresh ingredients. Over the lunchtime period service users stated they were happy with the food, making comments such as “ The food is excellent.” “It’s like you’d make for yourself.” They also confirmed that there is a choice of food of equal quality served at each meal time. It was noted that there was a choice of a meat dish and fish dish on the day of the Inspection and that service users Windlesham Manor DS0000021291.V251999.R01.S.doc Version 5.0 Page 11 were given a choice of several desserts and hot and cold options for their evening meal. The dining room is split into two areas and service users can choose where they would like to sit. Is large and spacious with plenty room for the use of mobility aids. Those service users, who choose to, help with the laying of the table and clearing the plates away at the end of the meal. Windlesham Manor DS0000021291.V251999.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The complaints procedure is adequate service users feel confident that their complaints would be listened to. Service users are protected from abuse. EVIDENCE: Service users commented that they felt safe. They also said that they would go to the manager if they had a complaint of any sort. Several service users commented on how approachable the manager and staff are and that they would feel comfortable about making a complaint if they had to. Information about how to make a complaint is displayed in the hallway. Policies and procedures relating to Complaints and Adult Protection were examined and found to be adequate. All staff receive training on Adult Protection issues and of what constitutes abuse. Windlesham Manor DS0000021291.V251999.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,24,25,26. This home is maintained to a high standard it is clean, hygienic and safe. Service users rooms are personalised and comfortable. EVIDENCE: This home is maintained to a high standard. In addition to care staff, staff are employed specifically to undertake maintenance and domestic duties. Records are kept of all the maintenance carried out in the home and are updated on a daily basis. These were examined and found to be up to date and in order. All areas of the building were found f to be clean, tidy and hygienic. A large conservatory has recently been completed. This provides an alternative seating and recreational area to the two existing lounges and separate dining areas. The standard of the decoration and furnishing of all areas of the home is of a high standard and homely in character. The gardens and grounds are well maintained and accessible to service users via ramps. Part of the garden has been redesigned and landscaped. Service Windlesham Manor DS0000021291.V251999.R01.S.doc Version 5.0 Page 14 users stated that it is an improvement. The manager explained that further improvements are planned for the remaining areas of the gardens. Service users’ own rooms are suitable and meet all the required standards for space. Most service users have chosen to bring their own furniture but it can be provided if preferred. Service users have the choice of having a key to their own rooms and this is specified in their care plan subject to a risk assessment being completed. Windlesham Manor DS0000021291.V251999.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30 Staff are trained and competently meet the needs of the service users. The required pre employment checks are not always carried out prior to deploying new staff in the home. EVIDENCE: Documentary evidence was examined which confirmed that staff undergo the induction and training required to work in a care home and that they were completed within the recommended timescales. Additional training is provided for staff to meet specialist needs of individual service users. All the staff responsible for administering medication have received appropriate training. Three staff recruitment files were examined. In the case of two individuals a Protection of Vulnerable Adults (Pova) First check had not been completed prior to them being deployed in the home. An immediate requirement was made for these checks to take place. The other required checks and recruitment procedures had been carried out satisfactorily. Feed back from service users was positive with comments such as “The staff are very kind - there is much to offer here.” “ It is the warm and caring atmosphere which makes it so special. There is laughter, which is essential to feeling at home.” Another said “All the staff are lovely – no complaints at all.” Windlesham Manor DS0000021291.V251999.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,37,38. This home is run in the best interest of the service users. The management and administration systems are good. EVIDENCE: The registered Manager is experienced and has the level of responsibility required for her to manage the home effectively. The manager explained that she has a good working relationship with the owner of the home. She also explained that service users are consulted with whenever possible but especially on issues that will affect them. Minutes of residents meetings were examined and confirmed that the residents had been involved in the planning of the new garden layout and their views and thoughts on these plans had been sought. The home has no involvement at all with the service users finances. Windlesham Manor DS0000021291.V251999.R01.S.doc Version 5.0 Page 17 Health and safety of service users and staff is promoted and records of completed maintenance reports were examined. Monthly risk assessments are carried out on the building and garden and a record is made of any action required. This is then transferred into a maintenance / repair book. These records were examined and evidence seen of work requested and completed. There is also a maintenance logbook for every room tin the building detailing all the work that has been carried out, by whom and when. Windlesham Manor DS0000021291.V251999.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 X X 3 4 4 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 3 X X 3 3 Windlesham Manor DS0000021291.V251999.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP33 Regulation 26 Timescale for action That the registered provider, or 30/12/05 suitable delegate, carries out and records an unannounced visit to the home, at least on a monthly basis, in order to monitor its performance and the quality of care being provided. A copy of this report to be forwarded to the Commission. This requirement was made at the last Inspection. That a plan is produced for the 30/12/05 longer-term management of the home to include the appointment of a manager, who holds the NVQ at level 4 in Management, or equivalent, together with the Registered Managers Award. This requirement was made at the last Inspection. All the required checks must be 01/11/05 carried out prior to staff being deployed in the home. 50 of the care staff employed 30/12/05 in the home must obtain NVQ Level 2 in Care. Requirement 2. OP31 9(2)(b)(i) 3. 4. OP29 OP28 19(1a,b) 18(1a) Windlesham Manor DS0000021291.V251999.R01.S.doc Version 5.0 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP19 Good Practice Recommendations That any recommendations made, following the inspection of the premises by the Environmental Health Department, are carried out, in particular respect of kitchen hygiene e.g. flooring and periodic deep cleaning. That the registered provider applies for a variation to the homes registration, to include the care of residents, who become confused. 2. OP4 Windlesham Manor DS0000021291.V251999.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Windlesham Manor DS0000021291.V251999.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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