Inspection on 03/05/05 for Windlesham Manor

This inspection was carried out on 3rd May 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Windlesham Manor 19/02/07

Windlesham Manor 01/11/05

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 Mike Flint Unannounced 03 May 2005 10.00 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 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 H59-H10 S21291 Windlesham Manor V220529 030505 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Windlesham Manor Address Hurtis Hill Crowborough East Sussex TN6 3AA 01892 652470 01892 652470 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 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 (OP) 40. of places Windlesham Manor H59-H10 S21291 Windlesham Manor V220529 030505 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of residents to be accommodated will be forty (40). 2. The residents will be aged sixty five (65) or over on admission. Date of last inspection 09 Janaury 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 ensuite 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 H59-H10 S21291 Windlesham Manor V220529 030505 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out during a day in early May, when there were thirty-seven (37) residents. Both the registered manager and shift senior assisted with the inspection. The Inspector spoke with duty staff, the relief cook and the handyman. It was also possible to speak with the owner, to whom feedback was given in respect of the inspection findings, at the end of the day. An inspection of a selection of records showed these to have been maintained up to date and accurately. Three of the residents were spoken with in private and group discussions took place between residents and the Inspector, over morning coffee and afternoon tea. What the service does well: What has improved since the last inspection? Planned improvements to the home’s physical environment are continuing; much of the garden has been re-designed to provide improved access from the newly constructed conservatory extension. The full-time gardener/ handyman maintains the premises in a very good state of repair and redecoration has been ongoing. The owners and registered manager show a high level of commitment towards staff training and development. Five staff have achieved their National Vocational Qualifications in Care at level 2, with six others working towards these awards at levels 2 and 3. There is a staff-training plan for the year, with various courses pre-booked. The emphasis on training for staff has a beneficial impact on the quality of care provided in the home. Windlesham Manor H59-H10 S21291 Windlesham Manor V220529 030505 Stage 4.doc Version 1.20 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Windlesham Manor H59-H10 S21291 Windlesham Manor V220529 030505 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Windlesham Manor H59-H10 S21291 Windlesham Manor V220529 030505 Stage 4.doc Version 1.20 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 standard(s) 3,4,5,6 People who are referred to the home are fully assessed enabling decisions to be taken in respect of the home’s ability to meet individual resident’s needs. EVIDENCE: Pre-admission assessments are completed for all new referrals to the home. Health and/ or Social Care assessments are provided for residents, who are to be funded. Arrangements are made for prospective users of the service and their relatives to visit the home prior to admission for a trial period. The assessments then form the basis of the care plan and include an evaluation of any risks that may be posed to the resident. Arrangements are in place for meeting the needs of residents, who become confused, including relevant training for staff in dementia care. The Inspector recommended that the home’s conditions of registration be revised to include this aspect of care provided at Windlesham Manor. Residents in the home appeared very settled and appropriately cared for; those spoken with during the inspection confirmed this view. The service does not offer intermediate care. Windlesham Manor H59-H10 S21291 Windlesham Manor V220529 030505 Stage 4.doc Version 1.20 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 standard(s) 9,10,11 The quality of care shown in providing individual support to residents in the home maximises their well-being, dignity and respect. EVIDENCE: A monitored dosage system is in use and all staff that administer medication have had training provided by the visiting pharmacist. Appropriate arrangements are made for the administration and storage of controlled drugs. Currently there are no service users who retain responsibility for their own medication. The pharmacist visits the home very regularly to oversee the systems that are in place, providing advice and guidance to staff if required. The manager said that visitors to the home were always made to feel welcome and that residents could be seen either in the privacy of their own rooms, or in one of the communal rooms, as they wish. Most residents have their own private telephone lines and told the Inspector how much they valued this. The home has a policy on death and dying and aims to support residents to stay at the home, provided their needs can still be met, without detriment to the level of care available to other residents, and with the agreement of all parties concerned. Windlesham Manor H59-H10 S21291 Windlesham Manor V220529 030505 Stage 4.doc Version 1.20 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 standard(s) 12,13,14,15 The home provides a relaxed and supportive environment that enables residents to pursue their interests and autonomy within a socially orientated setting that is beneficial to their wellbeing. EVIDENCE: A varied range of activities are offered, including exercise classes, walks, knitting, quizzes and gardening as well as various social events that take place from time to time. Regular church services are held at the home and there are also some activities especially arranged for those residents who are becoming confused. There are two staff employed to arrange and oversee the various activities. Two of the residents spoken with said that they also enjoyed helping with simple domestic chores e.g. setting and clearing the dining tables. Residents are able to have visitors at any reasonable time, who may be received in residents’ private rooms or in one of the several communal areas, including the garden. There are no restrictions on visitors to the home other than may be indicated by individual residents themselves. Residents are encouraged to make lifestyle choices, wherever possible and may bring personal items into the home on admission e.g. furniture, pictures and ornaments. Inventories are recorded for the benefit of all new admissions. The home has a four-weekly menu plan; any special diets or preferences are catered for. Residents are consulted with before menus are revised. Catering staff include a full-time cook, kitchen assistants and relief catering staff. Windlesham Manor H59-H10 S21291 Windlesham Manor V220529 030505 Stage 4.doc Version 1.20 Page 11 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 standard(s) 16,17,18 Any matters of concern are handled appropriately, reassuring those involved that they are being listened to and that action will be taken, as necessary. EVIDENCE: There have been no complaints recorded, or received by the CSCI since the last inspection. The home has a written procedure that advises residents, or visitors to the home how to make a complaint; a copy of this is displayed in the hall. Residents said that the owners and manager were very approachable and responsive, should issues arise that required action. Residents’ legal rights are protected and all are included on the electoral register; postal voting forms are available for those who wish to take part in local, or general elections. Those who do not retain responsibility for their own affairs have a next-of-kin, or other person acting for them. There are detailed policies and procedures in place relating to adult protection and abuse; staff have received training in these areas of their work. Police checks are carried out for all staff employed in the home. Windlesham Manor H59-H10 S21291 Windlesham Manor V220529 030505 Stage 4.doc Version 1.20 Page 12 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 standard(s) 19,20,22,24,26 The home provides a pleasing environment that is accessible, safe and well maintained, meeting residents’ individual and collective needs in a very comfortable, homely style. EVIDENCE: Windlesham Manor H59-H10 S21291 Windlesham Manor V220529 030505 Stage 4.doc Version 1.20 Page 13 The home is well maintained by the owners and a full-time employed handyman. The standard of décor, lighting and furnishings throughout the building is domestic in character and of good quality. The choice of communal areas includes two lounges, separate dining room and a large conservatory, which the owner confirmed is shortly due to be completed; one, or two residents commented that they were looking forward to being able to access this new area. The manager said there would be a party to celebrate. The spacious garden and residents’ greenhouse is kept safe and tidy and is readily accessible to residents via ramping. Residents’ private accommodation is very comfortably furnished. Residents may furnish their own rooms and many do so. All bedroom doors have locks fitted that provide privacy but at the same time are accessible to staff in an emergency. Residents are provided with keys, subject to risk assessment. The manager confirmed that any adaptations, or equipment would be provided, should this be required, following a review/ re-assessment of any individual resident’s needs. All areas, accessed by residents are kept very clean, hygienic and free from any odours. Appropriate policies and procedures are displayed e.g. infection control and COSHH procedures. The fire safety arrangements meet the requirements of the fire brigade and are routinely inspected. Recommendations made, following a recent visit from the Environmental Health Department, have yet to be complied with e.g. replacement of kitchen floor covering. Windlesham Manor H59-H10 S21291 Windlesham Manor V220529 030505 Stage 4.doc Version 1.20 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 The staff have a good understanding of the residents’ support needs, evident from the positive relationships, which have been formed between staff and residents, observed during the inspection. From the staff recruitment records inspected it was apparent that a revised application form, which included a full employment history, would provide information that was decisive in judging the suitability of those who wished to work with vulnerable people. EVIDENCE: Satisfactory staffing arrangements include six care staff plus ancillary staff in the morning; four care staff and an activities co-ordinator are employed in the afternoons and there are three waking night staff. A cook or chef is available for all meals and some young workers are employed to assist with household tasks e.g. in the kitchen and at meal times. In addition to the staff that have already achieved NVQ awards, others are undertaking this training. Both the manager and her assistant are qualified assessors. All new staff receive induction and foundation training, which meets the TOPSS specification. Additionally there is a wide range of training opportunities for staff, including safe working practice topics for the protection and safety of residents. The Inspector examined staff recruitment records and recommended that the basic application form be revised to give more detailed background information, including a full employment history and health statement. Windlesham Manor H59-H10 S21291 Windlesham Manor V220529 030505 Stage 4.doc Version 1.20 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,38 Windlesham Manor is a well managed home that is efficiently run day-to-day by the qualified manager and senior staff, ensuring the health, safety and welfare of residents as far as reasonably practicable. EVIDENCE: The registered manager has many years relevant experience and appeared well organised; the Inspector was impressed by the very orderly office and administrative systems that reflected this. Although she does not have a management qualification the manager undertakes periodic training to update her knowledge and skills. Both she and the assistant manager are qualified NVQ assessors and are due to attend supervision skills training. It is planned that an understudy for the position of registered manager will undertake the required training, prior to the present manager’s retirement. The manager has considerable delegated responsibilities and there are clear lines of accountability between the manager and the registered providers. Windlesham Manor H59-H10 S21291 Windlesham Manor V220529 030505 Stage 4.doc Version 1.20 Page 16 Staff spoken with on the day of the inspection commented on the approachability of the management in the home, where there is a clear sense of sound leadership and good morale. Satisfaction surveys have been sent out to residents and their relatives; helpful feedback is being obtained in this way. Feedback forms are also available in the entrance hall for use by service users and visitors to the home, who may wish to record their comments. Informal residents meetings are held on a regular basis; residents said that they were encouraged to raise any issue for discussion. The Standards require that additional quality assurance measures should include an annual development plan and regular self-monitoring of the home’s performance by the registered provider, or a representative. A business and financial plan was not available at the time of the inspection. However, the home appears to be soundly managed, whilst enjoying high occupancy levels, year on year; there was no reason to question the home’s financial viability, at this time. Appropriate insurance cover is in place. Appropriate steps are taken to ensure a safe working and living environment for service users and staff; relevant training and written policies support this, providing the necessary evidence. Health and safety checks and environmental risk assessments of the building are carried out; records are kept of this and of any accidents that may occur. Windlesham Manor H59-H10 S21291 Windlesham Manor V220529 030505 Stage 4.doc Version 1.20 Page 17 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 4 4 x 3 x 4 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 2 3 2 x x x x 3 Windlesham Manor H59-H10 S21291 Windlesham Manor V220529 030505 Stage 4.doc Version 1.20 Page 18 NO Are there any outstanding requirements from the last inspection? 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 33 Regulation 24(1) Requirement Timescale for action 01.11.05. 2. 33 26 3. 31 9(2)(b)(i) 4. 29 18(1)(a) That the registered provider establishes and maintains systems for reviewing, at appropriate intervals, and improving the quality of care provided at the home; these to include an annual development plan for the home. That the registered provider, or 01.07.05. 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. That a plan is produced for the 01.11.05. 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. That staff application forms are 01.11.05. revised to include full employment history and health status enquiry. Windlesham Manor H59-H10 S21291 Windlesham Manor V220529 030505 Stage 4.doc Version 1.20 Page 19 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 19 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. 3. 4. 04 Windlesham Manor H59-H10 S21291 Windlesham Manor V220529 030505 Stage 4.doc Version 1.20 Page 20 Commission for Social Care Inspection 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 H59-H10 S21291 Windlesham Manor V220529 030505 Stage 4.doc Version 1.20 Page 21 - 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. 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