Willow Grange Care Home

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last inspection we rated this key question good. At this inspection the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider promoted a positive culture of safety; however, they were not always proactive in their approach. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Following a serious incident, lessons were learnt, and the provider had put in place a number of processes to reduce the risk of reoccurrence. However, despite the provider’s own policy stating people should be closely monitored for 24 hours following a head injury, robust processes were not in place to ensure this monitoring took place and was recorded to enable staff to identify a decline in a person’s health. Also, not all staff spoken with were aware of the need to do this. Action was taken by the registered manager during the inspection to address these concerns.

Policies in place to guide staff had been updated but not fully reviewed to ensure the information and guidance they held was clear and up-to-date. The registered manager confirmed they would review these documents following the inspection.

All staff spoken with were aware of the lessons learnt following the serious incident. A member of staff told us, “If someone had a fall, one of the first things I’d do is check if they were on blood thinners and if they were I would definitely call 999.” Staff were aware of the immediate actions to take in the event of an accident or incident.

People told us they felt safe and were supported by staff who knew them well and listened to their concerns.

Healthcare professionals reported the service responded appropriately to requests for changes in people’s care needs.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Pre-assessment processes were in place and arrangements made for both people and family members to be involved in decisions about their care. A relative told us, “It was a smooth process, there was a questionnaire to fill in about people important to [person] and their likes and dislikes… it helped the transition process.” A member of staff told us, “Seniors will give information on new residents at handover, give you all the basic stuff and medication, and then you go and meet them and then look at their care plan.”

Staff told us they were informed of people’s needs prior to them moving into the service through care plans, risk assessments and updates given at handover. They confirmed good systems of communication were in place to ensure information was shared across shifts. A member of staff reported, “[If there are] any changes in needs, there’s an update in the care plan and at handover.”

Healthcare professionals reported the service made referrals to appropriate partners where required in a timely manner.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Where safeguarding concerns had been raised, they had been reported to the local authority and acted on appropriately. However, the provider had failed to correctly notify CQC of these events as the member of staff given this task had not been provided with appropriate training. This was addressed following the inspection.

We saw people appeared to be well cared for and had positive relationships with the staff who supported them. People approached staff for support, and it was provided with a smile and a kind word. One person told us, “They [care staff] have been so good to me. I feel safe.” A relative commented, “My loved one feels safe and says that they [care staff] are very caring. They know what [person] likes and what they can do. They are always clean when I see them and there are no complaints.”

People told us they felt safe when supported by staff. People and their loved ones told us they were confident if they raised concerns they would be listened to, and appropriate actions would be taken.

Staff had received training in recognising signs of abuse and were aware of the actions they should take if they had concerns. One member of staff told us, “I would tell the senior first of all” and another said, “If a resident complains about abuse I will report to senior and if not on [shift] I will go to the manager or to CQC.”

The provider worked with people to understand and manage risks to people. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Following a serious incident at the service, the coroner had issued a Regulation 28 Report to prevent future deaths, to the provider, highlighting a number of matters of concern that had come to their attention and requesting actions were taken to address these concerns. We looked for evidence these actions had been taken during the inspection.

Although the provider had updated their policies and processes following the serious incident, the system in place to accurately record a deterioration in a person’s condition was not robust. Following the inspection this was addressed, and systems were put in place which reflected the provider’s own policy and ensured staff recorded their observations of people following an incident in line with the provider’s policy.

Systems were in place to ensure risk assessments were immediately updated following an accident/incident and this information was shared with staff. Staff confirmed communication between shifts was good and they were kept up to date with changes in people’s care needs.

The registered manager had introduced a root cause analysis process in order to investigate and learn lessons from any accidents or incidents. However, the registered manager had failed to ensure interviews with staff following these investigations were robustly recorded. Following the inspection, action was taken to address this.

People told us they felt staff understood the risks to them and staff were able to explain the risks to the people they supported. Staff told us care plans and risk assessments gave them the information they required to support people safely.

Risk assessments were in place and were updated following accidents and incidents and when new information regarding people’s care needs came to light. A member of staff told us, “The risk assessment gives me everything we need. There is a monthly review of care plans, and we chat with family as well [about any concerns]”. A relative told us, “A care plan was drawn up in the beginning, but I haven’t seen it since. However, I do feel involved in [person’s] care. They need two carers to move them but there are no problems with the care staff. If there were any problems I can talk to the staff.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

We observed a number of areas of the building were tired and worn. People living at Willow Grange had also raised these concerns in their surveys. A window restrictor on the first floor landing was not fully secure.There was a lack of signage around the building to assist people when orientating the building and the decoration was not dementia friendly. We noted 2 pieces of bathroom equipment were worn and rusty, creating a potential infection control risk. One door in a communal area would not open and it appeared a fire hydrant in the same communal area had not been serviced. All the above were bought to the attention of the registered manager during the inspection and action was immediately taken to address the concerns raised. Assurances were obtained that the fire hydrant had been serviced, and this was an administrative error.

There were a number of safety checks in place completed by the maintenance man and senior staff. Following the inspection the registered manager arranged for an audit of the building and an action plan was put in place to address the areas identified.

We observed the building to be clean and odour free. People told us they had no concerns regarding the cleanliness of the building.

We observed people were supported to maintain their independence and walk around communal areas freely and without restriction.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

A tool to establish staffing levels based on people’s dependency levels had recently been introduced to reassure the registered manager that staffing levels in place were sufficient to meet people’s needs. People had no concerns regarding staffing levels, and we observed staff respond to people in a timely manner. One person told us, “There are always staff around when you need them. They have been golden.” A relative commented “There’s enough staff when I’ve been in – I’ve set the alarm off in the room and they responded quickly. Same at weekends. Staff are all very patient with the residents.”

Staff told us generally there were enough staff to support people and respond to their needs in a timely manner. One member of staff told us, “The manager will get someone in to cover if someone is ill, it works well and we have a good team now, in the beginning with agency it was a nightmare. We have a good skill mix now.”

Call bell monitoring took place on a daily basis to ensure they were not only in working order, but that staff responded to people’s calls for assistance, promptly.

People were supported by staff who had been safely recruited. Staff received an induction which included mandatory training and shadowing more experienced staff. Staff received regular supervision, and all staff spoken with told us the registered manager was supportive and approachable. One member of staff said, “When you go to the manager they ask you, ‘do you have any problems with the work?’ They are a manager of actions. I feel listened to, and it makes me feel safe.”

There was a training matrix in place which provided the registered manager with oversight of staff training levels. Staff told us they felt well trained and supported in their role and the electronic care planning system in place provided them with ‘all the information we need’ [to support people]. One member of staff said, “I am having all the necessary training, you never stop learning.” However, the provider had failed to ensure sufficient training was given to staff regarding the completion of CQC notifications. This was arranged following the inspection.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

We identified two pieces of equipment in bathrooms that had rust on them and posed a potential infection control risk. We also noticed a metal bin in another person’s bedroom had rust on it. The registered manager arranged for these items to be removed and replaced and new plastic bins were ordered for all service user’s bedrooms.

It was noted a number of areas where the building was tired/worn and could potentially be an infection control risk. Following the inspection the registered manager had arranged a complete environmental audit of the home and an action plan was now in place to address the areas that required attention.

People and their families told us their rooms were cleaned regularly and we observed areas were clean and the home was odour free. One person told us, “They [housekeeping staff] are very thorough when it comes to cleaning, for example, they will clean every handle on the cabinet individually.”

Staff had received training in infection prevention control and had their competencies assessed.

Staff confirmed they had access to ample supplies of personal protective equipment. One said, “They [management] don’t let you go in the kitchen without a hairnet.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People reported they were supported to receive their medicines as prescribed, and they had no concerns regarding their medicines management. One person told us, “My pills are brought to me three times a day and they are always on time.”

Staff had their medication competencies assessed, and medicines were stored correctly.

Medication audits were in place to identify any potential medication errors. Where people required medication as and when required, protocols were in place to direct and guide staff regarding the circumstances in which these medications should be administered. The team leader had created additional information for staff providing details on each medication prescribed, what it was for and the risks to people if not administered or if they overdosed.