Hallmark Willingdon Park Manor Luxury Care 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. This is the first assessment for this newly registered service. This key question has been rated 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 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. There was clear process in place to demonstrate learning taken forward. Incidents were investigated thoroughly and used to inform changes within the home. Any complaints were managed and monitored on an electronic system. Staff told us how any incidents were discussed with them in the daily handover meeting and then feedback was given to individual areas if necessary. People told us they knew how to raise any concerns and who to talk to if they needed to.

One person told us, "I have had no falls or accidents. No concerns.”

The provider 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 had pre assessments prior moving into the home. People had hospital passports in place, and these went with people to ensure that if they attended appointments, they went smoothly.

The registered manager told us, "We carry out pre assessments, we gather information and ask for personal photos for people bedroom doors."

One person told us, “I had a look around, very safe here due to the staff and surroundings, locks on the doors. I use a walker.” Another person told us, "Yes, I feel safe, security is good, I had a pre-assessment in hospital before I came here.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Safeguarding policies and robust procedures were in place, and any concerns were raised quickly and appropriately. Staff were confident in telling us about their safeguarding training and demonstrated their knowledge. People told us they felt safe, one person said, “I do feel safe, I always check that my patio door is locked at night, security is good here.”

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 MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). DoLS had been applied for, where required, and was monitored to ensure they remained relevant for individuals.

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. Care plans were detailed and personalised and risk assessments were in place for identified needs. Staff knew people well and understood potential risks people might face and were knowledgeable on how to try and reduce those risks and keep people safe.

People had specific risk assessments in place, for example, guidance around cutting up food.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Hallmark Willingdon Park Manor Luxury Care Home was well laid out and was easily accessible to everyone living there. There were lots of facilities for people to access, and we saw people moving independently around the home and making use of its facilities, such as the cinema room, sweet shop and hair salon. Regular monitoring took place to maintain a safe environment. Equipment was checked regularly to ensure it was maintained and safe to use.

One person told us, “On the whole yes, I would recommend the home, lovely facilities, very clean and tidy, ‘tip top” like a show house. I would not move now it is as good as it can get.”

The provider 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. Safe recruitment procedures were in place. Staff were confident with the level of training they had received. We received mixed feedback about staffing levels from people and staff. However, we received assurances from the registered manager about actions that had been taken since these concerns had been raised. The registered manager told us, "Some relatives raised concerns about staffing levels and call bell response times being too long, we do daily and weekly and monthly monitoring of call bell response times. We completed a care team analysis, to make sure we had enough staff, we looked again following relative’s feedback. There was a resident dependency tool in place to monitor people’s needs to ensure that staff were allocated accordingly.”

Staff told us, "I do enjoy my job, we support each other a lot."

Another person told us, “Staff make me feel safe, even the reception staff, all wonderful, especially the gardener, very helpful. No one I don’t like, no abuse or falls."

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The home was clean and well maintained. Personal Protective Equipment (PPE) was available around the home and staff were observed using PPE correctly. There was an IPC lead who carried out regular spot checks, this is a member of staff with a special interest in this area. The provider ran IPC forums for staff, which was a meeting to discuss infection prevention and control.

One person told us, “Home is clean and spotless." Another person told us, “All very clean and tidy here.”

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. A medicine round was observed, and medicines were administered and stored safely. The home worked in collaboration with the community medicine team. Staff demonstrated a good knowledge of different medicines and what they were for.

One person told us, “Staff are very particular with giving my medication, it never runs out.” Another person said, "There is a good understanding around my medication, I ask and they tell me.”