Archived: Willow Lodge

The registered manager of Willow Lodge had left employment unexpectedly four months prior to our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements of the Health and Social Care Act and associated regulations about how the service is run. The deputy manager had taken on the role of acting manager and was on duty throughout the inspection process.

At the last inspection on 6 December 2016 we rated the service as ‘Requires Improvement’. This was because four breaches of legal requirements were found. These were in relation to person-centred care, safe care and treatment, safeguarding service users from abuse and improper treatment and good governance. At that time Willow Lodge was placed in special measures because the area of ‘safe’ was rated as ‘inadequate’. Therefore, we took steps to ensure people were made safe and the provider submitted an action plan detailing the improvements they planned to make. Comments contained in the action plan were considered during this inspection.

We found at this comprehensive inspection on 03 October and 10 October 2017 the provider had met the legal requirements in relation to person-centred care and safeguarding service users from abuse and improper treatment. However, the concerns previously raised in relation to safe care and treatment and good governance had not been adequately addressed. Therefore the provider continued to fail to meet the legal requirements of the regulations in these areas. We also found the provider did not meet the required regulations in relation to fit and proper persons employed. The domains of ‘safe’ and ‘well led’ were rated as ‘inadequate’ and therefore Willow Lodge remains ‘inadequate’ overall and in special measures.

People who lived at Willow Lodge told us they felt safe being there. Fire procedures were readily available, so that staff were aware of action they needed to take in the event of a fire. However, we found parts of the environment to be unsafe and the management of medicines was poor. There was no evidence available to demonstrate all systems and equipment within the home had been appropriately serviced to ensure they were safe and fit for use. Records were not available about how people needed to be assisted from the building, should evacuation be necessary. Therefore, this was a continuous breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found that quality monitoring systems had been implemented, but these were not always effective, particularly in relation to medicines management, care planning, recruitment and safety and suitability of the premises. The plans of care were in general well written documents. However, the ones we saw had not all been reviewed and updated to reflect people’s current needs. Although the provider was aware of this; action had not been taken to address these failings. Therefore, this was a continuous breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Recruitment practices adopted by the home were poor. Appropriate background checks had not been conducted, which meant the safety and well-being of those who used the service was not adequately protected. There was no evidence on the staff personnel records that induction programmes had been completed by new employees. This was a breach of Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Business continuity plans were in place, should evacuation be necessary. However, key staff had not received training in this area. We made a recommendation about this.

We noted that attention to detail in relation to the environment was lacking. We made a recommendation about this.

The plans of care we saw were not always being followed in day to day practice and the provision of activities was limited. We made recommendations in these areas.

We saw people were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems adopted by the home were in accordance with the principles of the Mental Capacity Act 2005 (MCA). Records showed detailed Mental Capacity Assessments had been conducted before applications to deprive someone of their liberty were submitted. However, relevant documentation was not retained for those who had legal authority to act on a person’s behalf. We made a recommendation about this.

The acting manager had notified us of any significant events, such as deaths, safeguarding referrals and serious incidents.

We found the risk assessment process in relation to health and social care was satisfactory and systems for the recording of safeguarding incidents had been implemented. The staff team had received training in safeguarding adults and whistle-blowing procedures. Staff members we spoke with were confident in making safeguarding referrals, should the need arise.

We noted there was always a staff presence within the communal areas of the home and people looked comfortable being with staff members. We observed some good interactions between staff and those who lived at Willow Lodge and we found people’s privacy and dignity was, in general respected throughout the day. Staff members were seen to be kind, caring and compassionate.

Where agency workers were used, then these were often the same members of staff, which helped to promote continuity of care and support.

Records showed supervision sessions for staff were completed, although these could have been more structured. Annual appraisals had not been implemented. We made a recommendation about this.

Staff told us they received effective training and they gave some good examples of learning modules, which they had completed. Certificates of training were retained on the personnel records we saw. However, the training matrix did not match this information. We made a recommendation about this.

Meal times were pleasant and relaxed and people we spoke with were complementary about the staff team. They felt they were treated in a kind, caring and respectful manner. People expressed their satisfaction about the home and the services provided.

People we spoke with were aware of how to raise concerns, should they need to do so. A complaints procedure was in place at the home and a system had been implemented for the recording of complaints received. The service worked well with a range of community professionals. This helped to ensure people's health care needs were being appropriately met.

Regular meetings were held for the staff team. This enabled those who worked at the home to discuss topics of interest in an open forum. People's views were also gained through processes, such as satisfaction surveys. However, we made recommendations around the provision of meetings and gathering feedback about the quality of service provided.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

The last inspection of this location was conducted on 26 October 2015 and 6 November 2015, when we found several breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to safe care and treatment, premises and equipment, dignity and respect, person-centred care and good governance. We served a warning notice in relation to none compliance with Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We did not receive any representations from the provider. Actions the provider took in response to our findings at the last inspection are identified below.

This inspection was conducted on 6 December 2016 and it was unannounced, which meant that people did not know we were going to visit the home.

The registered manager was on duty at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements of the Health and Social Care Act and associated regulations about how the service is run.

At our last inspection on 26 October 2015 and 6 November 2015 we found the registered provider had not ensured systems and processes had been established to effectively assess, monitor and mitigate risks relating to the health, safety and welfare of service users. Therefore, this area was in need of improvement, so that the service could be sufficiently monitored under a continuous assessment process and any improvements needed could be identified and addressed in a timely fashion.

This was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We made a requirement about this. The provider sent us their action plan, which showed that actions would be completed by 15 April 2016.

At this inspection we found that quality monitoring systems had been implemented, but these had not always identified shortfalls recognised by the inspection team and therefore they were not consistently effective, particularly around medication management, where we found some significant shortfalls. Therefore, this constituted as a continued breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At our last inspection on 26 October 2015 and 6 November 2015 we found that the registered person had not ensured that the premises were properly maintained throughout. This was a breach of regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We made a requirement about this.

The provider sent us their action plan, which showed that actions in relation to the premises were on-going.

During the course of this inspection we toured the premises and found that significant improvements had been made to the environment. Several areas of the home had been decorated, upgraded and modernised. More suitable flooring had been installed in the lounge area and new furniture had been purchased, including profile beds. The laundry department had been upgrade. Therefore, the breach of regulation 15 had been met.

At our last inspection on 26 October 2015 and 6 November 2015 we found that the registered person had not ensured that people were consistently treated with dignity and respect. This was because we observed several poor care practices during our inspection. This was a breach of regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We made a requirement about this. The provider sent us their action plan, which showed that actions would be completed by 31 January 2016.

At this inspection we found the environment to be calm and staff members were interacting well with those who lived at Willow Lodge. People looked happy and interested in day to day activities. We did not observe any failings in relation to privacy and dignity. Therefore, the breach of regulation 10 had been met.

At our last inspection on 26 October 2015 and 6 November 2015 we found that the registered person had not ensured that the plans of care always reflected people's current needs. This was a breach of regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We made a requirement about this. The provider sent us their action plan, which showed that action would be completed by 31 March 2016.

At this inspection we found the care planning system had improved. It was well structured and, in general person centred. The plans of care had been reviewed regularly and any changes in need had been recorded well. However, we found that not all assessed needs had been recorded within the plans of care. Therefore,

this constituted as a continued breach of regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At our last inspection on 26 October 2015 and 6 November 2015 we found that the registered person had not protected people against the risk of receiving inappropriate or unsafe care and treatment, because medicines were not being well managed. This was a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We served a warning notice, as there were significant shortfalls in relation to medicines management. The provider sent us their action plan, which showed that action would be completed by 31 March 2016.

At this inspection we found continuing significant concerns, in relation to the safe management of medicines. Therefore, this constituted as a continued breach of regulations 12. At our last inspection on 26 October 2015 and 6 November 2015 we found that the registered provider had failed to assess and identify risks to the health and safety of people who used the service and had not done all that was reasonable practicable to mitigate such risks. This was a breach of regulation12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider sent us their action plan, which showed that actions would be completed by 31 March 2016.

At this inspection we found that a wide range of risk assessments had been introduced in relation to people's health, safety and welfare. However, the information was not always linked closely with the plans of care and therefore strategies implemented in order to reduce potential harm were not always evident. We also found that assessments had not always been developed in relation to some areas of identified risk, such as behaviours that challenged the service. We were told by the registered manager that plans were in place to dismantle the conservatory, which was currently serving as a dining room, as it did not promote a pleasant dining area for those who lived at the home. We also found that several bedroom doors slammed shut and were in need of adjustment, in order to prevent entrapment injuries and one bedroom door did not fit properly into the door frame. Therefore, the findings above constituted a continued breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At our last inspection on 26 October 2015 and 6 November 2015 we found that the registered provider had not protected people against the risk of receiving inappropriate or unsafe care and treatment because infection control practices were poor. This was a breach of regulation12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider sent us their action plan, which showed that actions in this area were on-going.

During this inspection we found that significant improvements had been made to the environment. The home was warm and comfortable throughout. There were no unpleasant smells noted and the home was clean and hygienic throughout. Therefore, this part of the breach of regulation 12 had been met.

At our last inspection on 26 October 2015 and 6 November 2015 we found that the registered provider had not protected people's health and safety because they had not ensured that persons providing care or treatment to service users had the competence, skills and experience to do so safely. This was a breach of regulation12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider sent us their action plan, which showed that actions in this area were

on-going due to continual training.

At this inspection we found that a varied training programme had been introduced for the staff team, which helped them to keep abreast of current practices and any changes in legislation. Regular supervision sessions for staff and annual appraisals were also being conducted. Therefore, this part of the breach of regulation 12 had been met.

Fire procedures were easily available, so that people were aware of action they needed to take in the event of a fire and records we saw provided good information about how people needed to be assisted from the building, should the need arise. Records showed that equipment and systems within the home had been

serviced in accordance with the manufacturer's recommendations. This helped to protect people from harm.

Records showed that Mental Capacity Assessments had been conducted, in order to determine capacity levels. The rights of people were protected as applicatio

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with those who used the service, their relatives, support staff and the manager and from looking at records. We were able to speak with four people who lived at Willow Lodge. They all gave us positive responses to the questions we asked.

If you want to see the evidence supporting our summary please read our full report.

Is the service safe?

People we spoke with told us they felt safe living at Willow Lodge and their dignity was always respected. Systems were in place to help managers and the staff team to learn from untoward incidents, such as accidents. This helped the service to continually improve.

The home had proper policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards. Applications were made, as was needed. This helped to ensure people's freedom was not being unnecessarily restricted. People (or their relatives) were involved in making decisions about the care and support provided.

At the time of our visit to this location, we looked at infection control protocols. We found the environment to be clean, hygienic and pleasant smelling throughout. Equipment was well maintained and serviced regularly. Therefore, people were not put at unnecessary risk.

Is the service effective?

People were supported to access advocacy services, if they wished to do so. This meant they could have additional help from an independent person, if they wanted it. The health and personal care needs of those who used the service had been thoroughly assessed, with a range of people involved in their care and support.

Systems were in place to ensure the practices of the home were effectively assessed, so the quality of service provided could be consistently monitored. A broad range of training modules were provided for staff, with regular mandatory updates. This helped to ensure the staff team delivered effective care and support for those who lived at the home.

People were supported to move around the home freely and safely. Visitors confirmed they were able to see people in private and visiting times were flexible.

Is the service caring?

We asked those who lived at the home about the staff team. Feedback from them was very positive. They said staff were kind and caring towards them and helped them to meet their needs. We saw that people were offered a range of choices throughout the day and they were supported to remain as independent as possible.

When speaking with staff and observing their interactions with those who lived at Willow Lodge, it was clear they genuinely cared for those they supported and were seen speaking with people in a respectful and friendly manner.

People's preferences and interests were well recorded and care and support was provided in accordance with people's wishes. One person commented, "I like doing things here. I like painting and drawing." A relative told us, "We got a good feeling about this place, when we came to have a look around. We had been to see plenty homes, but this seemed to be the friendliest and most caring."

Is the service responsive?

People completed activities in and outside the service regularly. Staff were seen to be responding to people well by anticipating their needs appropriately.

The home worked well with other agencies and services to make sure people received care and support in a consistent way. Evidence was available to show Willow Lodge responded well to any suggestions for improvement and appropriate action was taken to rectify any shortfalls identified.

Is the service well-led?

The service had a quality assurance system in place and records showed that identified problems and opportunities to change things for the better were addressed promptly. As a result, the quality of service provided was continuously monitored.

Staff spoken with had a good understanding of their roles. They were confident in reporting any concerns and they felt well supported by the managers of the service. People who lived at Willow Lodge and their relatives completed satisfaction surveys periodically. Systems were in place so that any shortfalls or concerns raised could be taken on board and dealt with appropriately.

Care plans reflected people's needs, preferences and diversity. They were sufficiently detailed to make sure peoples' care and support would be provided according to their needs and safety. Lifestyle profiles provided staff with insight into peoples' life experiences and values.

People who had limited communication were represented in their best interests to ensure decisions made about their care were right for them.

We looked at records and found care and support was planned and delivered in a way that ensured people's safety and welfare.

People who use the service were protected from the risk of abuse, because staff had been trained on identifying and responding to signs and allegations of abuse. We observed people were comfortable around staff and showed no sign of fearful or concerning behaviour around them.

People were cared for by staff that had character checks as to their suitability to undertake caring duties, and who were trained.

Standards of quality and safety were being monitored and there was a continuing improvement plan being followed.

A family member said they were very happy with the standards and described the service as 'A care home run by people who care'.