Willowbrooke Residential 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 good. At this assessment the rating has remained 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 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 identify and embed good practice.

People and their relatives seemed to suggest there was an open dialogue of communication with the management and staff. Staff knew how to report concerns and partners felt the provider works with them, and takes appropriate action when things go wrong.

We were able to review examples of lessons learned shared in staff meetings, and after safeguarding’s, however further work could be done to drive improvement in this area. The registered manager told us how they would look to implement this. Accidents and incidents were being recorded, and appropriate action was being taken.

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.

People felt the staff team worked well together to ensure they received the care and support they needed. One relative told us, “[Person] went into hospital a few times as a result of [medical conditions]. They (The staff) called an ambulance. One of the carers (staff member) stayed with them and made them aware of their condition.” Staff spoke about information that was being shared at handovers and from seniors and managers.

Professionals felt the service made referrals in a timely way. One professional said, "They are proactive with things sometimes before we even get here." Another professional told us how the service have gone above and beyond to support safe systems, pathways and transitions. They told us, "100% yes, I think they go over and above. They had a person on respite, and they needed a lot of support, they supported [person] to get an appropriate placement. [Person] got a bond with someone that was already moving due to their complex needs, so they got them a placement together. The feedback from the service she moved to was excellent. I

haven't seen this type of support before.” Handover sheets were in place to support sharing of information with staff coming onto shift. We were able to see some examples where appropriate referrals had been made when people needed external support.

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.

People told us they felt safe. One person said, “Oh, yes, yes (I feel safe), everybody makes you feel safe.” Staff were knowledgeable about safeguarding and had completed safeguarding training. One staff member said they would report, “Abuse and neglect." Appropriate safeguarding’s were being made based on the information recorded on the accident and incident log we reviewed. The service had a safeguarding policy in place which detailed necessary information. A signing in book was in place to ensure the service had an accurate record of any visitors which helped keep people safe.

Staff were able to confidently explain about mental capacity. One staff member said, "It is about if somebody is able to retain information and has the capacity to make decisions.” A Mental Capacity and Deprivation of Liberty Policy and procedure was in place. We saw examples of mental capacity assessments that had been completed.

The registered manager confirmed people could access advocates if they needed this support, but no one did need this support.

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 and their relative’s felt risks were being managed. One relative told us, “One of the issues that caused [person] to come in the service was because [of a medical need]. They haven’t (had an issue with this) since they came into the service.” Staff spoke about how they manage various risks.

Necessary risks assessments were in place, when needed relating to people’s health and potential risks. We were able to see examples of some environmental risk assessments that were in place, though the service would benefit from a whole service risk assessment completing to ensure all areas were covered. We found appropriate personal emergency evacuation plan records were in place.

The service detected and controlled potential risks in the care environment, where issues were identified, they acted immediately. They made sure equipment, facilities and technology supported the delivery of safe care.

People and their relatives felt their loved one was in a safe environment. Fire safety checks were in place. The environment was safe, though we did find that some wardrobes were not secured to the walls, this was rectified immediately. Radiator covers and window restrictors were in place and there was adequate signage around the service. Necessary safety certificates confirmed checks had been completed to support safe environments in areas including gas safety, electricity and legionella checks. Servicing of equipment that was used to move people, needed to be completed as no current certificate could be produced. The provider and registered manager ensured this was done during our inspection.

The environment was neutral and well maintained and people’s doors had their names on. Improvements to the environment that could benefit people living with a dementia at the service was discussed with the management team. The registered manager acknowledged this and advised they would investigate this further. One staff member said of the environment, "I think it is very much about trying to make it a home from home environment."

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.

Records confirmed staff training was up to date and staff told us they completed an induction when they started in post. Staff supervisions and appraisals were taking place, in line with policy.

The service had a dependency tool to help calculate required staffing levels based on people’s needs and staffing levels were in line with this. Agency staff was beingused to help ensure staffing levels were consistent. People’s feedback on staffing levels was mixed. One person told us, “I do think at times we could do with more (staff), at any time of the day or night.” Whilst someone else said, “I think there is (enough staff), night time is covered, there is always someone there.” One staff member told us, "It (staffing levels) is ok, but I think there are times of the day when we need 3. Maybe around mealtimes."

Safe recruitment practices were mostly being followed, and appropriate checks were in place, though potential gaps in applicants work history and their qualifications needed to be better recorded. The registered manager told us they would look to ensure this was completed going forward.

The service assessed and managed the risk of infection. They had processes in place to detect and control the risk of it spreading.

The service was clean and tidy and there was a dedicated area for laundry. Appropriate personal protective equipment was in place. Cleaning records were up to date and were being appropriately completed.

Relatives felt the servcie was clean. One relative said, “Yes, it is very clean and tidy, they clean [persons] room regularly. The carpets also get cleaned regularly.” Staff told us how they try to prevent or control the spread of infection. One staff member said, "I clean things, I wear aprons and gloves."

Medicines processes and oversight of topical applications was not always safe, though there was no impact on people because of this. Appropriate guidance was available for staff.

Medicines were mostly administered safely; however, we did witness one person receive a when required medication without checking administration records. The deputy manager undertook competency and supervision of the staff member involved to ensure they were competent, and an investigation was completed. Creams were not always safely managed. We found some out of date creams in people’s rooms, and we found one staff member had applied cream to a person that was not on their medication administration record. The registered manager took immediate appropriate action to resolve this issue.

Although fridge temperatures were being regularly taken, an appropriate fridge thermometer was not in place, meaning we were not confident recordings were correct. The registered manager immediately ordered the correct thermometer to rectify this and confirmed this had been installed.

Oral medication was being securely stored. Controlled drugs were safely managed. Appropriate guidance was in place for staff to follow and staff had received training in medicines administration. Relatives said they felt their loved ones received their medication safely. One relative said, “[Person] takes medication, and they always give them to them.”