8 December 2018
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
This was a comprehensive inspection which took place on 01 November 2018 and was unannounced. The membership of the inspection team comprised of three inspectors and an expert by experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.
When planning our inspection, we looked at the information we held about the service. This included notifications received from the provider about deaths, accidents/incidents and safeguarding alerts, which they are required to send us by law. Before the inspection, the provider completed a Provider Information Return (PIR). This is a form that asked the provider to give some key information about the service, what the services does well and improvements they plan to make. We contacted the Local Authority commissioning service and the Clinical Commissioning Group [CCG] for any relevant information they may have to support our inspection. We also contacted Healthwatch Birmingham who provide information on care services.
During our visit we met with seven people who use the service and spoke to four relatives, eight members of care staff, three health care professionals, the quality assurance manager, the training manager, the registered manager and the provider.
Many of the people had limited verbal communication and were not always able to tell us how they found living at the home. People who could not communicate verbally used other methods of communication, for example; gestures. We also carried out a Short Observational Framework for Inspection (SOFI), which is an observational tool used to help us collect evidence about the experience of people who use services, especially where people were not able to tell us verbally.
We looked at the care records of four people and three staff files as well as the medicine management processes and records that were maintained by the provider about recruitment and staff training. We also looked at records relating to the management of the service and a selection of the service’s policies and procedures to check people received a quality service.
8 December 2018
Willowbrook provides accommodation and nursing care for up to 75 people. People living in the service may have dementia and or enduring mental health conditions.
The service comprises of two buildings; Aldridge House, which has accommodation for 45 people diagnosed as living with dementia, and Alexander House, which has a 15 bed wing for people with mental ill health and 15 beds for people living with dementia.
At the last rating inspection in June 2016, the service was rated Good. At this inspection we found the service had developed further and was now Outstanding.
There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
People were kept safe and secure from risk of harm. Potential risks to people had been assessed and managed appropriately by the provider. People received their medicines safely and as prescribed and were supported by sufficient numbers of staff to ensure that risk of harm was minimised. The provider had introduced enhanced systems to ensure people remained safe within the home.
The provider and their staff had continued to show a high level of compassion and kindness when caring for people, demonstrating a dedicated person centred approach to supporting their care and well-being. Feedback from people, relatives and healthcare professionals were extremely positive and complimentary, all providing glowing endorsements of how caring and compassionate staff were towards their loved ones.
People’s rights to privacy were respected by the staff and their dignity was maintained and upheld at all times. People were supported to express their views and be actively involved in making decisions about their care and support needs, by a provider who valued their input. Staff consistently sought people’s consent before providing care and support.
The provider demonstrated a high level of responsiveness to people’s individual care and support needs. They knew people well and understood how to help people live a happy and content life. We saw that activities and events were tailored specifically in response to people living with dementia. Staff demonstrated that they understood the importance and benefits of providing person centred care
The provider led by example and there was a strong ethos for quality care which ran throughout the location. All stakeholders had input into the running of the home, their feedback was valued and used to drive forward quality service provision. People, relatives and staff were proud of being part of the home and its positive and uplifting culture. Systems and processes were extremely robust and effective ensuring that quality standards were met and exceeded. The provider was proactive in working with external stakeholders, sharing information and examples of good practice, to develop the service and support external service provision.
People using the service, their relatives and staff were confident about approaching the registered manager if they needed to. They were extremely complimentary about the provider, registered manager and the whole workforce. They recognised that their views were valued and respected by the provider who consistently used their feedback to support quality service development.