Willowbeech Also known as Willowbeech Limited - 33 Ophir Road

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

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Staff understood the importance of reporting accidents and incidents and felt confident raising any concerns. The manager had clear systems in place to review incidents and reduce risks to people. Staff described the working environment as positive, with regular training and supervision. They said they felt well supported by the manager and were able to share ideas to improve care. Relatives were kept informed about any changes. The manager had a good understanding of people’s needs and maintained effective oversight of the care provided.

The service 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.The service worked effectively with people and health professionals to ensure safe support. Relatives and staff said care decisions were clearly communicated, and referrals were made in a timely manner when required. The manager maintained positive working relationships with external professionals. Staff appeared well informed about people and had good working relationships with each of them. Regular team meetings offered opportunities for open discussions on all areas of care, including risk management.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately. We observed staff and people spending time together, and people were relaxed. Safeguarding procedures were well established, and staff were confident about how to raise concerns. The provider responded appropriately and without delay to potential safeguarding concerns and met legal requirements, including submitting timely notification of relevant events to CQC. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. A staff member said, “Safeguarding is taken seriously at Willowbeech, staff are always encouraged to raise concerns and follow correct procedures to ensure people’s safety and wellbeing.’’ Staff understood how to report safeguarding concerns and were clear about the process within the service. The service operated in line with the principles of Mental Capacity Act 2005 (MCA) principles, and all Deprivation of Liberty Safeguards (DoLS) applications had been properly managed. The manager had oversight of DoLS authorisations to ensure records were accurate and conditions were met. Staff had completed safeguarding training and demonstrated a good understanding of their roles and responsibilities.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. People were encouraged to take an active role in managing their own risks. Staff delivered care that was both safe and supportive, while enabling people to participate in activities meaningful to them. We observed staff supporting people to move safely around the service, using the appropriate equipment. Staff told us they had access to sufficient information about people’s risks and made use of the electronic care planning system. The manager explained risk assessments were reviewed and updated regularly, and they had liaised with external professionals to help manage risks. Risk assessments covered all areas of people’s care and support needs, considering individual circumstances and shared environments.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.We observed people appearing relaxed and at ease while using various areas of the service including communal spaces. The manager was clear about their responsibilities to maintain a safe environment and explained the measures in place to achieve this. Potential environmental risks were identified and managed. The service ensured that equipment, facilities, and technology were maintained to support the safe delivery of care. Required safety checks, including gas and fire safety, were carried out by external specialists and contractors. Each person had a personal emergency evacuation plan (PEEP), and the fire alarm system was tested on a weekly basis.

The service 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. Procedures were in place to ensure the required checks were carried out on staff before they commenced their employment. This included enhanced Disclosure and Barring Service (DBS) checks for adults. DBS checks provide information including details about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions. We observed there were enough staff on duty to meet people’s needs, and feedback from relatives confirmed support was available when required. Staff treated people with dignity and respect, acknowledging their individual preferences. Training was relevant to their roles and was ongoing, with supervision and appraisal processes in place to ensure safe and effective care. Staff told us they received enough training to carry out their roles competently.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.We found the service to be clean and well-maintained. People felt comfortable, and their relatives told us the service was clean and tidy. The service proactively assessed and managed infection risks, taking steps to prevent the spread of infection and reporting any concerns to relevant agencies in a timely manner. Staff told us they had completed training in infection prevention and control and had access to personal protective equipment (PPE).

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. Staff recognised the importance of following safe medicines procedures. We observed people’s medicines were administered safely and in accordance with individual needs, capacities, and preferences. People were involved with how their medicines were managed, including during medicines reviews. Safe systems were in place for the ordering, storage, administration, and disposal of medicines. Staff were trained to administer medicines in line with prescriber instructions and told us they felt confident in medicines practices within the service.