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Inspection report

Date of Inspection: 14 August 2014
Date of Publication: 7 October 2014
Inspection Report published 07 October 2014 PDF


Inspection carried out on 14 August 2014

During an inspection looking at part of the service

The inspection was carried out by an adult social care inspector. At the time of our inspection 16 people were living in the home. A number of the people at Willow House were not able to communicate their experience of living in the home. To help us to understand the experiences of these people we used our SOFI (Short Observational Framework for Inspection) tool. The SOFI tool allowed us to spend time watching what was going on in the home and helped us to record how people spent their time, the type of support they got and whether they had positive experiences. In addition we spoke with four people who could tell us their experiences and the relative of one person


We also spoke with the registered manager, two health professionals, two care workers, one cleaning and one catering staff member. We looked at documents including care plans and management reports.

We considered information we held about the home to decide on the focus of the inspection. All of the evidence we had gathered under the outcomes we inspected was used to answer the five questions we always ask;

� Is the home caring?

� Is the home responsive?

� Is the home safe?

� Is the home effective?

� Is the home well led?

Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the home caring?

Overall we found that the home was caring. People told us that staff were caring and this was supported by the positive interactions with people we saw during the inspection. A relative told us that they were kept informed of their loved one�s care and welfare.

Is the home responsive?

The home was not always responsive. People�s care had not always been planned to ensure their welfare was maintained. Though staff could describe the action the home took to respond to people�s changing health needs including ensuring they ate and drank enough, these changes had not always been recorded in peoples care plans to ensure that people would receive the care they required.

A visiting health professional told us that the home contacted them promptly when people�s behaviour changed and implemented their guidance. However, this guidance had not been recorded in people�s care plans to ensure that staff would implement it consistently.

Is the home safe?

The home is not safe at this time. The home identified risks to people�s safety but records did not always provide staff with sufficient information to ensure that people were protected from the risk of falling or their behaviour harming them or others. The home was undertaking some maintenance to the lift and repairing the fire damage. The provider did not have written risk assessments in place to ensure that safety plans in relation to the maintenance work was robustly communicated with staff and the safety arrangements monitored.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DOLS) which applies to care homes like Willow House. The manager had an understanding of how the Mental Capacity Act (2005) and DoLS applied to people in the home and was working with the local authority to complete the required DoLS authorisations.

The home had undertaken a robust fire safety audit. A fire risk assessment and personal evacuation plans were in place to ensure the home managed the risk of fire appropriately.

Is the service effective?

The service was effective. The home was meeting people�s nutritional needs and was reviewing the number of staff over weekends to ensure that they maintained consistent quality of care across the whole week.

Is the service well led?

The service was not always well led. Though systems were in place to assess the quality and risks relating to the service, records were not always kept to support the registered manager to monitor the home�s compliance with legal and professional guidance for example in relation to falls and recruitment.