Care Home: Windlesham Manor

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What the care home does well Windlesham Manor provides an attractive, comfortable and well maintained environment for service users requiring residential care and support. There is a well-established staff team, many who have worked in the home for a number of years. There are sufficient numbers of staff on duty at all times. All residents spoken to stated that the staff are respectful of their needs and that the food in the home is of a high quality. There is a good programme of activities in place with a wide range of pastimes available suiting different needs and abilities. The home also employs two activities co-ordinators. Medication processes in the home are well managed. What has improved since the last inspection? The home has improved the processes for care planning and risk assessment, which provide a greater focus on the needs and guidance for meeting those assessed needs. Further work could still be completed to develop these further however. Work has been completed to improve the deep cleaning in the kitchen area. What the care home could do better: 3 recommendations have been made as a result of this inspection process. These relate to developing guidance in the care planning processes and reviewing the system for daily records to ensure confidentiality is maintained. The home should also provide adult protection training for all staff to ensure competency in this area. CARE HOMES FOR OLDER PEOPLE Windlesham Manor Hurtis Hill Crowborough East Sussex TN6 3AA Lead Inspector Joseph Harris Unannounced Inspection 31st March 2008 10:30 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.V359543.R01.S.doc Version 5.2 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.V359543.R01.S.doc Version 5.2 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 611000 01892 613404 enquiries@windlesham-manor.co.uk 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.V359543.R01.S.doc Version 5.2 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 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, a large dining room, and a conservatory, which has increased the communal space available for residents. Information on the range of fees charged was confirmed in the pre-inspection questionnaire prior to the inspection with fees approximately ranging from around £395 to £580 per week with extra changes for personal items. Windlesham Manor DS0000021291.V359543.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This key unannounced inspection process culminated in a site visit to the home on 31st March 2008. The site visit commenced at approximately 10:30am and concluded at 4.30pm, lasting for around 6 hours. During the course of the visit a tour of the premises was undertaken and discussions were held with the registered manager, staff members and service users. A range of documentation was examined relating to the residents, staff, medication, health and safety and the day-to-day running of the home. An ‘expert by experience’ was present for the site visit who spent time with service users. An ‘expert by experience’ is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. The home also returned the Annual Quality Assurance Assessment (AQAA), which provides information to inform the inspection process. What the service does well: Windlesham Manor provides an attractive, comfortable and well maintained environment for service users requiring residential care and support. There is a well-established staff team, many who have worked in the home for a number of years. There are sufficient numbers of staff on duty at all times. All residents spoken to stated that the staff are respectful of their needs and that the food in the home is of a high quality. There is a good programme of activities in place with a wide range of pastimes available suiting different needs and abilities. The home also employs two activities co-ordinators. Medication processes in the home are well managed. Windlesham Manor DS0000021291.V359543.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Windlesham Manor DS0000021291.V359543.R01.S.doc Version 5.2 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.V359543.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. The home assesses the needs of service users prior to admission. The home does not offer intermediate or respite care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The majority of prospective service users are referred privately, but the home does equally except referrals through care management processes. 3 individual service user files were examined all of which contained preadmission assessments. Where possible the home requests joint assessment information from care managers. The manager aims to visit prospective service users in their current accommodation in the first instance to begin the assessment process. If appropriate the individual is invited to spend time in Windlesham Manor DS0000021291.V359543.R01.S.doc Version 5.2 Page 9 the home following this. The registered manager gains information from relevant professionals, family members and the prospective service user themselves covering key topics. A preliminary assessment form is used covering the care and support needs of each individual and more complex issues are explored in greater detail. These assessments form the starting point for the development of plans of care. The home does not provided respite or intermediate care services. Windlesham Manor DS0000021291.V359543.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. Each service user has a well-developed plan of care and their healthcare needs are met. Medication processes are well managed. Service users are treated with dignity and respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 3 individual service user plans were examined during the site visit all of which had a well established plan of care and support in place. In each case the home had put together an informative and well written life history providing an interesting summary of life events for each resident. The plans of care are succinct and to the point, but address all the key areas of need. There is sufficient information to ensure that all areas of need can be met in a consistent manner. However these could be developed in greater Windlesham Manor DS0000021291.V359543.R01.S.doc Version 5.2 Page 11 depth where there are more complex issues providing more detailed written guidance. Refer to recommendation 1. The service user files contain a range of risk assessments covering key topics such as mobility, manual handling and fire amongst other topics that provide suitable guidance to minimise perceived risks. Pertinent information is recorded on a daily basis and communicated to staff coming on to shift. It was noted that the home uses a daily handover book that could compromise confidentiality. This was discussed with the registered manager and is a practice that should be reviewed. Refer to recommendation 2. The home maintains clear healthcare records for all service users and there is evidence that where a healthcare concern is noted this is referred appropriately. It was reported that the home receives very good support from community health and social care professionals. The home has good processes in place for the management and administration of medication. All medication administration records were up to date, clear and well maintained. The storage facilities are located in a secure position and were well organised. One member of staff has overall responsibility for medication systems and in discussion it was evident that she takes her responsibilities seriously and keeps systems under review. All staff administering medication have received appropriate training. Service users are treated with dignity and respect. Residents are able to choose where they spend their time, whether in communal areas or their own rooms. Staff were observed to knock before entering rooms and spoke to residents in a respectful manner. Each resident has a private telephone in their rooms. Service users all commented on the excellent attitude of staff and stated that they feel that their views and opinions are respected. Windlesham Manor DS0000021291.V359543.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. Service users have a lifestyle that suits their needs and visitors are welcomed into the home. The food is of a consistently high standard. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users have the benefit of a wide range of available activities and are encouraged to spend their time in a constructive way. The home provides a good range of opportunities ranging from informal games and social events to regular clubs and outside entertainers. A number of residents spoke fondly of the gardening club that is operation. The owners provide funds for the purchase of plants and areas of the garden, including a greenhouse, have been allocated for gardening club members to grow their plants. There are also exercise groups 2-3 times per week and a knitting circle. Entertainers visit the home on a regular basis and a hairdresser visits a number of times per week. There is a relaxed and friendly atmosphere in the home and seating is thoughtfully arranged to encourage small groups. Holy communion is held once Windlesham Manor DS0000021291.V359543.R01.S.doc Version 5.2 Page 13 a month and people with different religious needs are catered for. Residents commented that there is an interesting and varied lifestyle in the home and that there are always things to do. The home employs a full time and a part time activities co-ordinator who arrange and facilitate activities. Visitors are welcomed into the home at all reasonable times. There is sufficient space throughout the home to enable people to meet in private should they wish to do so. It was not possible to meet any visitors at the time of the site visit, but residents confirmed that their visitors are always made welcome. Residents are able to choose how they spend their time and a number of people stated that they choose to spend more time in their rooms. Residents are also able to choose where they eat their meals. A number of bedrooms were seen all of which had been adorned with residents personal possessions. Without exception, all residents commented on the quality of the food in the home. Residents are offered a choice of meals on a daily basis and there is a four-week rolling menu offering an interesting, wholesome and balanced diet. Residents are offered choice throughout the serving of the meals such as what type of drink they want. Through observation it was noted that the home could review their serving process as this role is fulfilled by one person and a number of residents wait for some time before receiving their food, which could be easily rectified with another server. Where residents require assistance with eating staff are on hand to help. The mealtimes were relaxed and unhurried providing a comfortable and social dining experience. Windlesham Manor DS0000021291.V359543.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. Service user’s views are listened to and acted upon. Residents are protected from forms of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are appropriate policies and procedures in place regarding complaints, and it was confirmed that these are followed when investigating any concerns raised at Windlesham Manor. The staff spoken with were knowledgeable regarding the complaint procedure and of how to start the process if the manager is not available. No complaints have been received by the CSCI or in the home since the last inspection. The Adult Protection policy in the home was found to be up to date and staff interviewed were knowledgeable about the systems in place to protect vulnerable service users. Not all staff have received training in adult protection and it is advised that this training is made available for all staff. Refer to recommendation 3. No adult protection alerts have been raised since the last inspection. Windlesham Manor DS0000021291.V359543.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is excellent. The premises are suited to the needs of the residents and are safe, wellmaintained, clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Windlesham manor is a large detached home set in the countryside close to the town of Crowborough. The home has a rich history having once been the home of Arthur Conan Doyle. There is a good sized car park at the front of the building, which is surrounded by accessible, well tended and attractive gardens. The house is a listed building and is well cared for both internally and externally. There is a good range of communal space throughout the building including a large lounge and dining room. There is additional space for small private meetings. A number of Windlesham Manor DS0000021291.V359543.R01.S.doc Version 5.2 Page 16 bedrooms were viewed during the tour of the premises, which were varied in size and shape all with en-suite facilities. There are a number of rooms that can be used as double rooms with three currently used for this purpose. All service users who share rooms that were spoken to stated that they are happy with these arrangements. The bedrooms have all been personalised according to taste and provide good space to meet the needs of each service user. The home employs a full-time maintenance man who ensure that all repairs and redecoration is completed in a timely fashion. There are toilet and bathroom facilities appropriately located throughout the house suitable for the needs of each individual. The laundry is well-equipped and is fit for purpose. There is a large kitchen with all required equipment that has been maintained in a clean and hygienic fashion. The home is clean and hygienic throughout with no offensive odours. All hazardous substances are stored appropriately and adequate infection control measures in place. The home meets the requirements of the environmental health and fire departments. Windlesham Manor DS0000021291.V359543.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. There are suitable numbers of well-qualified and experienced staff on duty at all times who are appointed through a robust recruitment procedure. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home operates with a good staff ratio at all times. There are 6 staff on duty during the morning with 5 staff in the afternoon/evening and 3 waking staff at night. The home has a flexible staff rota, which can be altered to meet the needs of the service users depending on the activities or appointments that are scheduled for each day. In addition to the care staff there is a large team of ancillary staff including a full-time administrator, chef, maintenance man, 4 cleaners and activities coordinators. The home offers a good training package and ensures that all staff work through an induction programme following appointment and complete all mandatory training within the first 6 months of appointment. Windlesham Manor DS0000021291.V359543.R01.S.doc Version 5.2 Page 18 There is a low turnover of staff with a number of staff members having worked at the home in excess of ten years. Over 50 of the staff team have at least an NVQ level 2 and new staff are expected to work towards this qualification. 3 staff personnel files were examined all of which contained the required information including CRB and POVA checks, two written references and proof of identity amongst other information. Staff were positive about their experience of working in the home. One staff member said, “I love working here, it’s like a second home.” Windlesham Manor DS0000021291.V359543.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. The home is well-run and in the best interests of the service users. Residents financial interests are safeguarded and the health, safety and welfare of service users protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has been in post for over 10 years and has worked in the home for approximately 20 years. She has a wealth of experience and demonstrates good management and clinical skills. She maintains a hands-on role in the home and staff and service users alike spoke positively of her influence. She has not obtained an NVQ level 4, but the deputy manager is currently working towards achieving these qualifications. Windlesham Manor DS0000021291.V359543.R01.S.doc Version 5.2 Page 20 The registered manager, owners and administrator conduct regular monthly audits of the home addressing all key areas of development and improvement. Service users and relatives have opportunities to provide feedback about the home on an annual basis in the form of surveys and any actions arising from this consultation are followed through appropriately. The home does not take on an appointee role with regard to any resident’s finances, but do provide a safekeeping service if required. Clear records are maintained of any incoming and outgoing transactions. A range of health and safety documentation was examined which was all in place and up to date. Fire records and accident records are maintained. All required service certificates including electrical wiring, gas safety and equipment and lift servicing. Environmental and fire risk assessments have been completed and are reviewed annually. Safe working practices are in place underpinned by policies and procedures and mandatory training. Windlesham Manor DS0000021291.V359543.R01.S.doc Version 5.2 Page 21 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X 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 3 X 3 X 3 X X 3 Windlesham Manor DS0000021291.V359543.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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. 2. 3. Refer to Standard OP7 OP14 OP18 Good Practice Recommendations The guidance in plans of care could be developed where complex areas of need have been identified. The home should review the use of the daily record book ensuring confidentiality is maintained. To provide adult protection training for all staff. Windlesham Manor DS0000021291.V359543.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection South East Region The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V359543.R01.S.doc Version 5.2 Page 24 - 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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