Willow Court Nursing 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 assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider had effective systems to record, monitor and review safety incidents. Accidents and incidents, including falls and wounds, were recorded on a quality governance dashboard and reviewed using a Red, Amber, Green (RAG) rating system before senior management sign-off. Management completed thematic reviews and shared learning through team meetings, handovers and staff briefings to help staff understand emerging themes and changes to practice. This supported learning to be shared consistently across the service and reduced the risk of similar incidents occurring.

The provider used learning from incidents to improve people's care and safety. For example, 1 person had experienced repeated incidents. Leaders analysed these, identified contributory factors and with the support of external professionals, implemented measures which had resulted in a reduction of incidents.

The provider responded promptly to concerns and complaints and used these to improve practice. People told us they would raise safety concerns with staff or the Home Manager, and staff demonstrated a clear understanding of reporting incidents promptly. A relative told us, "They [staff] rang me to let me know, they were really apologetic... the home was clear it would not happen again," and confirmed the incident had not been repeated. This demonstrated the provider promoted an open culture where concerns were acted on to improve people's safety.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

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

The provider had effective systems to identify, assess and manage risks to people. Risk assessments covered areas including choking, falls and bed rails. Assessments identified individual risks alongside measures to reduce harm and were reviewed when people's needs changed. This supported staff to deliver safe and consistent care that reflected people's current needs.

Staff balanced risk management with people's independence and choice. Staff described supporting positive risk-taking and working with people and healthcare professionals to make informed decisions safely. For example, 1 person who was at high risk of falls wished to continue mobilising independently in their room, and staff supported this while managing the associated risks.

People, relatives and staff consistently described being involved in managing risks. One person told us, "I feel safe and staff meet my needs... I need oxygen, and they manage this very well." A relative told us, "I was part of the risk assessment for them." Staff explained they discussed risks with people, respected their choices and involved relatives and healthcare professionals where appropriate.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider maintained effective oversight of the environment, equipment and safety systems. Safety certificates, servicing records and environmental risk assessments were up to date and identified actions to reduce hazards. Oxygen was stored safely, supported by appropriate signage and risk assessments. This supported the delivery of care in an environment that was safe and appropriately managed.

Leaders monitored environmental and fire safety through routine checks and planned maintenance. Records confirmed regular fire drills, weekly fire alarm and fire door checks, servicing of fire safety equipment and completion of legionella control measures. Personal Emergency Evacuation Plans (PEEPs) reflected individual risks, including oxygen use and the application of emollient creams. This reduced the risk of avoidable harm by ensuring assessments reflected people's individual needs.

The provider acted promptly to maintain a safe environment. Window restrictors and bed rails were checked regularly; wardrobes were secured to walls and adaptations supported people's mobility needs. Following previous incidents of people leaving the premises unexpectedly, leaders increased the height of the garden perimeter fence and completed a risk assessment. People and relatives consistently described the environment as clean, safe and well maintained. A relative told us, "The Home is always very clean and everything well maintained."

The provider did not always make sure there were enough qualified, skilled and experienced staff to meet people’s assessed needs. Staffing arrangements did not always support people to receive timely care.

Staff did not always receive training that reflected the needs of the people they supported. Although mandatory training was largely up to date, the training matrix identified gaps in condition-specific training despite staff providing care for people with those conditions. Staff had access to care plans containing guidance on recognising signs, symptoms and escalation processes, and we found no evidence that these training gaps had resulted in poor outcomes for people. However, without condition-specific training, leaders could not always be assured staff had the knowledge and skills to meet people's assessed needs consistently. Leaders had identified these gaps through their training oversight and were reviewing training requirements to better reflect people's assessed needs.

Feedback from people was mixed with some identifying occasions when staffing levels affected their experience, particularly during busy periods. Relatives' feedback was also mixed. One relative told us their family member had sometimes waited almost an hour for support to use the toilet during mealtimes. However, another relative told us staff responded promptly when people requested assistance, saying, "If she [Person] buzzes, staff come quite quickly. They always let her [Person] know if they cannot come immediately." This demonstrated people's experiences of timely support varied, particularly during busy periods.

Staff also described staffing pressures, with 1 saying, "Staffing levels are the biggest issue that needs improvement." Leaders used a dependency tool to inform staffing levels and were trialling a more detailed system that considered people's assessed needs alongside staffing hours.

During the inspection, management deployed an additional member of staff to support a person who became distressed following admission after their relative left the service. This demonstrated leaders responded promptly to changing risks and took action to maintain people's safety.

Leaders had systems in place to support safe recruitment, workforce development and staffing oversight. Staff were safely recruited and received regular supervision, competency assessments and annual appraisals.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

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.

The provider had effective systems to manage medicines safely. Medicine Administration Records (MARs) showed people received their medicines as prescribed, including medicines that needed to be administered at specific times. Medicines were stored securely.

Staff followed safe medicines practices and had access to clear guidance. Detailed protocols were in place for 'as required' (PRN) medicines and covert administration, reflecting general practitioner (GP) instructions and pharmaceutical advice where required. Staff had completed medicines competency assessments and demonstrated knowledge of the National Institute for Health and Care Excellence (NICE) medicines framework. This supported the safe and consistent administration of medicines.

People and relatives gave positive feedback about medicines management, which was reflected in our observations. One person told us, "I have Parkinson's and staff always make sure I get my medication at the right time." Relatives told us, "They manage his medication, no problems," and "GP changed her medication; they manage it all OK."

We observed staff explaining what medicines were for before administration, checking whether people required pain relief and applying moisturising cream with consent after identifying dry skin. Staff also described improvements that had been made to medicines management since the last inspection.