CQC report explained · a residential care home
What the CQC found at Windlesham Manor
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, May 2021
Inspected but not rated; inspectors were assured that infection prevention and control measures were in place.
The CQC made an unannounced, targeted inspection on 15 April 2021 after receiving concerns about infection control and prevention. It looked only at how the home prevented and managed infections.
Inspectors were assured that the home used protective equipment safely, supported testing, managed admissions and outbreaks, and followed shielding and distancing arrangements. They also found suitable cleaning, hygiene and visiting arrangements.
The home was inspected but not rated. This means the report does not give an overall quality rating or ratings for the other care areas.
Safer visiting arrangements
The home used a booking system and created a dedicated visiting room. People could also meet visitors outside when the weather allowed.
“A dedicated visiting room had been created with screens and seating which was distanced.” from the report
Keeping families informed
The home increased contact with families during pandemic restrictions, including emails, pictures and support with video and telephone calls.
“Regular emails from the service shared information and pictures about people's activity and menu options, celebrations and wellbeing.” from the report
PPE and cleaning
Inspectors saw PPE being used properly and found good supplies. Cleaning had been increased and was checked by the manager.
“PPE was observed to be appropriately worn and there were good supplies in place.” from the report
Managing infection risks
The home used zones and designated staff during a recent outbreak. People were supported to isolate while still receiving individual activities and social contact.
“During the recent COVID-19 outbreak zones had been created with designated staff allocated to each zone, this reduced the movement of staff through the building.” from the report
Inspectors raised no specific concerns in this report.
- 01What infection prevention and control arrangements are in place now, and what has changed since the inspection on 15 April 2021?
- 02How are visits arranged now, and is a dedicated visiting room or outdoor visiting available?
- 03How does the home manage a suspected or confirmed infection outbreak, including staff zones and isolation?
- 04How often are cleaning arrangements checked, and how are any problems recorded and corrected?
- 05What happened to the concerns about infection control and prevention that led to this targeted inspection?
This was an unannounced targeted inspection of infection prevention and control measures only; the service was inspected but not rated and the other care areas were not assessed. This explanation was written from the published report of 26 May 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, October 2017
Windlesham Manor was rated Good overall, with kind and safe care, but person-centred care plans and some call bell responses needed improvement.
This was an unannounced comprehensive inspection on 22 and 30 August 2017. Inspectors reviewed information about the home, watched care, spoke with 19 people, six relatives, staff and visiting healthcare professionals, and checked records.
The home was rated Good for Safe, Effective, Caring and Well-led. Inspectors found people were protected from abuse, medicines were managed safely, staffing met people's needs, and people received food, drink and healthcare. Staff were described as kind, respectful and knowledgeable about the people they supported.
Responsive care was rated Requires Improvement. Some care plans did not fully describe people's diagnoses or care needs. Some call bells had taken a long time to answer, and some complaints had not been recorded, although the home had started actions to improve these areas.
Safe medicines
Medicines were stored, administered and recorded safely overall. Staff checked people's identity, consent and medicine records, and controlled medicines were managed safely.
“There were suitable arrangements in place for the safe storage and administration of people's medicines.” from the report
Kind and respectful staff
Inspectors saw warm, respectful interactions. Staff knew people's communication styles, preferences and routines.
“Staff treated people dignity and respect. Staff were knowledgeable about people's likes, dislikes, preferences and care needs.” from the report
Activities and interests
People could choose from varied activities, including outings, exercise, gardening, music and sessions involving animals. The home also supported people to continue interests they had before moving in.
“People had access to a range of activities and were encouraged to pursue interests they held prior to living at the service.” from the report
Improved management checks
The manager and provider had introduced planned audits covering areas such as falls, nutrition, medicines and call bells. External audits were also being used.
“Quality monitoring systems were robust and the registered provider was utilising external sources to audit quality.” from the report
Care plans did not always give enough detail
needs fixingOne person's dementia needs were not properly described in their care plan. Another plan did not accurately explain when swallowing guidance should be used. Inspectors recommended reviewing all care plans.
“Some people had diagnoses that were not addressed in their care plans or guidelines that were not fully recorded in plans.” from the report
Some call bells were slow to be answered
needs fixingSeveral calls took between 10 and 28 minutes to answer in the week before the inspection. The manager introduced an audit and response times had reduced by the second inspection day.
“For the week preceding our inspection we found one call had taken 28 minutes to answer, another call 27 minutes to answer, one call 23 minutes” from the report
Some complaints were not recorded
minorComplaints were generally resolved appropriately, but some informal complaints had not been logged. The provider later introduced a central complaints and concerns log.
“We found some complaints that had been resolved appropriately and following the registered providers complaints procedure, but had not been documented.” from the report
- 01How do you make sure each care plan fully describes a person's dementia, swallowing needs and other diagnoses?
- 02What are the current call bell response times, and how are delays investigated?
- 03How are all complaints and informal concerns recorded and reviewed now?
- 04Which improvements to the building for people living with dementia have been completed since this inspection?
- 05How often are medicines records and application records checked for completeness?
This was an unannounced comprehensive inspection covering all five key questions and the overall quality of the home. This explanation was written from the published report of 27 October 2017 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Windlesham Manor
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- May 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- October 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- February 2017Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2015
Registered with the Care Quality Commission on 1 February 2015.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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19 live-in carers within about an hour of East Sussex
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,000 to £1,400 a week. 13 can care for a couple. 10 years' experience on average.
“When he point blank refused to go into hospital for a life saving blood transfusion she talked him through the situation and agreed to go in the ambulance with him and stayed until he was settled.”
“Una felt safe, secure and loved in her time with Debbie which is a gift that I am eternally grateful for.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.