17 August 2021
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
This inspection was carried out by two inspectors.
Service and service type
Willett Lodge is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.
Before the inspection we reviewed the information we held about the service. We looked at the notifications we had received for this service. Notifications are information about important events the service is required to send us by law. We used all this information to plan our inspection.
During the inspection
We spoke with two people who used the service and one relative about their experience of the care provided. We spoke with six members of staff including the provider, registered manager, care workers, housekeeping staff and the chef. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We reviewed a range of records. This included five people’s care records and multiple medication records. We looked at three staff files in relation to recruitment and supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
After the inspection
We spoke to three relatives and continued to seek clarification from the provider to validate evidence found. We looked at a range of information including training data, infection prevention and control documents, minutes of meetings and quality assurance records. We requested feedback from two professionals who regularly visit the service.
17 August 2021
About the service
Willett Lodge is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The care home provides accommodation and nursing care for up to 20 people in one adapted building. The home provides support for people living with a range of healthcare, mobility and sensory needs, including people living with dementia. There were 18 people living at the home at the time of our inspection.
People’s experience of using this service and what we found
People were not always protected from avoidable harm because risks to people's health and wellbeing were not consistently managed. Processes were not in place to ensure care plans and risk assessments were reviewed and updated following specific risk incidents or events. Care plans did not contain detailed and person-centred information to accurately reflect the needs of people and mitigate identified and potential risks.
There was no adequate process for ensuring that care recommended by specialist healthcare professionals was implemented. People's risk management plans lacked important detail to guide staff on how to keep people safe or manage specific health conditions.
Staff were recruited in accordance with the providers policy, although recruitment processes for agency staff were not always robust enough ensure that agency staff employed at short notice were inducted sufficiently, or had the skills, training and competence to provide safe care.
We observed a task focussed culture of the service which meant that care was not consistently person centred and did not always promote good outcomes for people. Staffing levels were not always sufficient in meeting people's emotional or psychological needs in a person-centred way, and staff did not always have time to provide structured, meaningful activities for people to engage in.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
People were cared for by staff who were kind and compassionate. People received support from a consistent team of staff who knew them well. Relatives told us they thought their loved ones were safe and there were enough staff to support them and meet their needs.
Staff had received training in infection prevention and control (IPC) and IPC practice within the home was aligned with current government guidance.
Rating at last inspection
The last rating for this service was Good (published 27 March 2018).
Why we inspected
The inspection was prompted in part by notification of a specific incident, where concerns had been raised regarding the security of the home. This incident is subject to a police investigation. The information CQC received about the incident identified concerns about the assessment and management of risks, people’s safety and neglect. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. This inspection examined those risks.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.
The overall rating for the service has changed from ‘Good’ to ‘Requires Improvement’. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Willett Lodge on our website at www.cqc.org.uk.
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.
We have identified breaches in relation to providing safe care and treatment, recruitment and the overall governance of the service at this inspection.
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.
After the inspection we contacted the provider about some of the urgent concerns found during inspection. The provider sent us assurances and evidence that informed us of the immediate actions they had taken to address these concerns.
We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.