Willow Brook

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

During our assessment of this key question, we identified 1 continued breach of the legal regulations in relation to safe care and treatment. People were still not always protected from risks associated with infection prevention and control and the score of 1 awarded to this quality statement limited the overall rating of the safe key question to Requires Improvement. Medicine records still did not always support the safe administration of people’s ‘as required’ medicines and flammable emollients. Staff had received appropriate training, but further development was required to ensure staff fully understood and followed good practice in relation to medicines and infection control. There were enough staff to meet people’s needs. Staff understood people’s risks and staff were recruited safely. People’s risk management plans had improved. Safeguarding processes were in place and were being followed by staff and leaders. The manager reviewed incidents, but further development was required to ensure learning from incidents were always shared with staff.

This service scored 63 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were not able to give us any feedback about how the service learned from incidents.

Some staff told us they did not usually receive feedback following incidents to ensure learning could take place. Staff we spoke with understood their responsibility to report accidents and incidents and most confirmed they completed incident forms as required. Staff had regular team meetings where they discussed how to support people who had complex needs. This enabled them to have a consistent approach when supporting people to prevent behaviour related incidents. The manager told us they were reviewing the appropriate safety alerts and sharing them with their team. They told us they shared learning with staff through team meetings, supervision and communication books.

We could not be assured that lessons learned from managers reviewing incidents were always shared with the whole team in order to support learning and improvement. Records showed only 1 meeting in May 2024 where incidents were discussed and shared with the team. There were 6 accidents/incidents which occurred between 1 June and 17 June 2024 which were not discussed in the June team meeting which took place on 27 June 2023. Improvements had been made following the last inspection in the reporting of accidents and incidents. We saw examples of medical advice being sought promptly following incidents. The provider used an incident, accident and near miss root cause tracker to help identify themes and trends.

People were not able to give us any feedback about safe systems, pathways and transitions.

Staff felt people would be admitted into the home safely. The manager told us they had not supported anyone with transition into the service since they had been working at the service. They told us how they worked with other agencies such as Occupational Therapists to carry out assessments and look at equipment people might need. The manager told us they had a pre- assessment document to support them to understand people’s needs and people would have the opportunity to make multiple visits to the service to determine if they wanted to live at Willow Brook. The manager was not always clear about the provider’s policies and all the steps they were required to take to keep people fully safe when admitting them into the service.

We received a mixed response from partners we spoke with about the service working in collaboration with them to ensure a smooth transition when the service started working with people. Professionals felt staff involved them when needed and wanted people to receive appropriate care. They told us they felt the service needed more support to ensure when people have complex needs these would be identified and people supported effectively.

Systems were in place to ensure people transitioned to the service in a safe manner. People’s records demonstrated their needs were assessed before they started using the service. Assessments included details of the range of health and social care services the person used and arrangements to ensure the support was maintained. These assessments included working in collaboration with other health and social care professionals. The provider had been supported through meetings with the local authority and the safeguarding team to improve people’s care records, including care plans and risk assessments.

People were not able to give us any feedback about their experience in safeguarding.

Staff had received safeguarding training and knew how to protect people from harm and abuse and would raise any concerns with the management team. Staff felt the management team would take their concerns seriously and keep people safe. The manager understood their safeguarding responsibilities and gave examples of investigations they completed. They discussed safeguarding in team meetings and in staff supervisions. The manager told us they checked incident forms to ensure any safeguarding referrals were raised as required.

People looked cared for and were well dressed. We did not observe any bad practice and staff effectively redirected people who were anxious or upset. We observed the atmosphere in the home to be relaxed and calm. Staff worked well with people, providing reassurance. We observed lots of positive interactions between staff and people. Staff were attentive to people’s needs.

Improvements had been made following our previous inspection. The provider had a more consistent approach to reporting safeguarding concerns to the local authority and CQC and had worked closely with the local safeguarding team to make improvements. The provider had a safeguarding policy in place which was current and in date. Records showed all staff had received training in safeguarding.

People were not able to give us any feedback about being involved to manage risk.

Staff told us people had detailed risk assessments and support plans to help them mitigate and respond to risks. Staff demonstrated they understood people’s risks. One staff said, “The risk assessment, lists things to help stop risks to people.” Staff were confident to respond in positive ways to people’s distress or agitation. They talked about changing staff members when needed, stepping away and trying to identify the trigger to support people to manage their distress. All staff had received behaviour support training. We heard examples of how risks were managed to support people to develop skills such as making hot drinks. Staff were kept up to date with people’s risk information through instant messaging and the manager checking that all staff have read the changes.

We observed staff members supporting people when they became distressed in accordance with best practice guidance. They were supportive and kind and offered redirection in line with their care plans, this led to prompt de-escalation of people’s distress. We observed staff members following the guidance in people’s positive behavioural support (PBS) plans.

People had risk assessments and care plans in place for most risks which helped staff to mitigate the risks to them. The information in people’s risk management plans had improved since the last inspection. They contained a lot more detail and were more person centred. More information was required in some risk management plans to include all of the detail staff would need to support people safely such as when making hot drinks. Other professionals were involved in supporting the team to manage risks and documentation relating to risks was shared with the staff team.

People were not able to give us any feedback about safe environments within the service.

Staff we spoke with confirmed they had received fire training, completed fire drills and knew how to evacuate people safely. One staff member told us, “We did some fire drills and noticed some hiccups in places, the response was to continue to do fire drills until we got it right and everyone knows what they are doing.” The manager told us they were regularly completing fire evacuations with staff and were working at ensuring all staff knew what to do in the event of an emergency. The manager completed health and safety checks once a month to identify any environmental improvements that might be required. They said, “It is a large document which covers a lot. Anything we find we escalate to the maintenance team or the relevant equipment owner.”

We saw window restrictors were in place to protect people from heights. The communal areas were tidy and free from obstruction and fire doors were fitted correctly with no gaps. However, 1 person’s bedroom had a suitcase and shoes in front of an external exit which the manager told us could be used to evacuate this person. This could pose a trip hazard when trying to evacuate the person in the event of a fire. During our onsite visit a locksmith was called to fix the lock of the laundry room door to ensure all cleaning products would be safely stored. The manager had plans in place to decorate one person’s bedroom and lounge area to ensure it would be inviting and personalised. Following our last inspection the provider had ensured the environment was free from hazards posed by refurbishments.

Improvements had been made in fire safety following the last inspection. Records showed since April weekly fire alarm checks had been carried out. Some time was needed to ensure these would continue to be completed as required. We reviewed the actions in the fire audit carried out by Hampshire Fire Services on 10 January 2024, all actions apart from monthly in-house checks of the emergency lighting had been completed. We spoke to the manager about this outstanding action, who told us, they were in the process of addressing this. At the last inspection staff had not received additional training to support safe emergency evacuation, placing people at increased risk of harm in the event of a fire. At this inspection improvements had been made and training had taken place. Where concerns with staff evacuations had been noted the manager had followed this up with the staff in their supervision. They were also carrying out fire evacuations during the evening to ensure staff practiced effective nighttime evacuation. At the last inspection staff did not know who the fire wardens were. At this inspection there was a clear notice identifying the staff warden on duty. Certificates for gas safety, electrical testing, PAT testing and servicing of fire equipment were all in date. People had Personal Evacuation Plans.

People were not able to give us any feedback about safe and effective staffing at the service.

Staff we spoke to, confirmed there were enough staff to provide safe care. Staff told us most of the agency staff had all worked at the service before and were regular agency staff that knew people. Staff told us, their training, which included an induction equipped them with the skills and knowledge to undertake their role. Training included Makaton which enabled staff to communicate with people who did not speak using signs and symbols. One staff member told us, “The induction takes almost 2 weeks. Every day you cover different aspects of induction, including first aid, policy and procedures, safeguarding. You are given proper training.” All staff we spoke to, confirmed they had a recent supervision. One staff member told us, “I have had supervision. I had feedback about what I am doing right and what I need to know.” The manager explained how they ensured there were always suitably trained staff on every shift.

During the onsite visit there were enough staff on duty to support people with their needs. People appeared to be in receipt of their 1:1 support and we observed positive interactions between people and staff. Staff responded promptly to people’s requests for assistance and gave them enough time to work at their own pace.

We reviewed staff rotas which confirmed there were enough staff to enable people to receive their assessed hours. The service used agency staff when required to ensure they had enough staff on duty. Records showed not all agency staff had an induction recorded to ensure they understood the service’s operating procedures. We spoke with the manager about this who told us they will ensure moving forward these were completed. Staff had completed the provider’s required training, however had not always followed correct procedures in for example infection control and safe management of people’s food. Safe recruitment processes were followed which meant staff were checked for suitability before being employed by the service.

People were not able to give us any feedback about infection prevention and control.

Staff had received infection control training and had access to personal protective equipment (PPE) to safely manage and control the prevention of infections. Staff told us, the training covered handwashing, food preparation to avoid cross-contamination, laundry and cleaning. Although we found concerns in relation to safe food management and cleanliness; the manager and staff we spoke with were not aware of these shortfalls or of the concerns about the cleanliness of areas of the home or that good food safety practice was not being followed when handling people’s food.

We carried out an observation of the kitchen area and saw similar concerns to those found at our last inspection. Infection prevention and control was not managed safely which placed people at risk of exposure to harmful bacteria and ill health. We found people’s food was not always in date or stored safely once opened, increasing the risk of contamination. We found some equipment was unclean, this included the microwave, some cupboards and tiles. There was a plinth missing under a cupboard, we observed cobwebs and food debris underneath. These posed an infection control hazard. The laundry room was unclean, including the floor, cupboards, sink and mop holder. We found bins without a self-closing lid increasing the risk of cross contamination. We found malodours in both people’s bedrooms. In 1 person’s room both the mattress and headboard were significantly stained. Their shower mat had significant amounts of mildew on the underside of the mat. This person had a support plan which alerted staff they had a rubber bathmat which could collect mildew if not cleaned after each use. We spoke to the manager about this, who told us a new bathmat was on order. We also noted their shower was unclean and both bathrooms had trim coming away from the wall posing an infection control risk.

Procedures put in place to ensure cleaning took place was not always effective. We reviewed cleaning schedules for the week commencing the 08 July 2024. The kitchen cleaning rota had been ticked as completed, however the kitchen was not always clean in areas we observed. The infection control audit dated 16 May 2024 and 15 June 2024, identified 1 person’s headboard needed to be cleaned and their flat required a deep clean, at the time of our assessment this had still not been completed. Following the assessment the provider told us they were addressing these concerns. A staff member completed another infection control audit during our assessment. Daily walk around checks completed for 4 weeks including June and July 2024 stated temperature recordings were up to date for the fridge and freezer located in the main kitchen. However, we did not find any July recordings (only for the staff fridge) and there were 7 days in June 2024 and 20 days in May 2024 when the fridge and freezer temperatures had not been recorded. This meant, we were not assured food had been stored at the correct temperatures. The daily walk around check did not include checking bin liners were in bins or checking bathmats, both of which were concerns we observed during the inspection. The daily walk arounds were not completed on Sunday’s which meant the cleanliness of the home and food storage was not being checked on Sundays. We reviewed 6 weeks of water checks. We noted on 4 occasions the water temperature was too high in a person’s flat. We spoke to the manager about this, who told us they were aware the temperatures were too high, and they went back each time and retested the outlet, and it reached safe level, so no further action was taken. However, this mitigating action was not recorded which meant this repeated issue had gone unreported.

People were not able to give us any feedback about how their medicines were managed.

Staff who administered medicines, and the manager were able to describe the provider’s procedures for administering medicines. They had received training relating to medicines and their competency to administer people’s medicines were assessed. One person was prescribed a flammable emollient. Staff did not all understand the fire risk associated with the build-up of emollient residue on clothing and bedding and the action they needed to take to minimise the risk. Staff were aware people were prescribed when required (PRN) medicines for different conditions including when people got anxious. However, they did not know when PRN medicines were administered, they needed to record the outcome, whether the medicine was effective and the action they needed to take if medicines did not have the expected effects. The manager told us they maintained oversight of the use of people’s sedatives and antipsychotic medicines during weekly discussions with the Complex Team at the GP practice. Thereby ensuring national guidance was followed to prevent the over medication of people with a learning disability, autism or both with psychotropic medicines.

People’s medicines were, stored and disposed of safely. People prescribed medicines to manage their anxieties had ‘when required’ protocols and positive behaviour support plans (PBSP) in place. These plans included appropriate alternative anxiety reducing support staff needed to provide before using medicines. Records showed on 2 occasions a person was administered medicine to manage their anxieties, however, the details as to why the medicines had been administered and the effectiveness of the medicine had not been recorded. Two PRN protocols for ‘as required' medicines did not contain sufficient detail to guide staff when and how to administer these medicines safely. For example, 1 PRN protocol detailed a medicine was prescribed to support a person to attend medical appointments, however, the protocol did not state how many hours prior to the appointment the medicines should be administered to ensure maximum effect. There were risk assessments in place to manage the risk of prescribed flammable emollients. However, 1 risk assessment did not contain sufficient detail about how to manage this risk safely. Both risk assessments did not detail there was still a risk of build-up of the emollient even after washing clothing and bedding as per National Patient Safety Alerts. The manager told us, they would update the risk assessments.