Willows Lodge Care Home

Updated 10 October 2023

The inspection

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 Health and Social Care Act 2008.

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.

Inspection team

The inspection team consisted of 2 inspectors. The team also included a nursing advisor and 2 Expert by Experiences'. The Expert by Experience's completed telephone calls to people's relatives. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Willows Lodge Care Home is a 'care home'. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Willows Lodge Care Home also provides nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 22 August 2023 and ended on 31 August 2023. We visited the service on 23 August 2023.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 13 people who used the service and 16 relatives about their experience of the care provided. We spoke with 10 members of staff, including the registered manager, deputy manager and director.

We reviewed a range of records. This included 9 people's care records and 5 people's medicines records. We looked at 5 staff files in relation to recruitment and staff supervision. We looked at the provider's arrangements for managing risk and medicines management, staff training data, complaint and compliment records.

Updated 10 October 2023

About the service

Willows Lodge Care Home provides accommodation, personal care and nursing care for up to 70 older people, people living with dementia and those who require nursing and palliative care. The service consists of 3 units: Poppy Unit for people living with dementia, Buttercup Unit for people who require nursing and palliative care and Rose Unit for people who require residential care. At the time of the inspection there were 63 people living at the service.

People's experience of using this service and what we found

People's care was not always delivered safely. Information relating to people's individual risks was not always recorded, up-to-date or did not provide enough assurance that people were safe.

Suitable arrangements were not in place to ensure the proper and safe use of medicines. The staffing levels and the deployment of staff was not suitable to meet people's care and support needs. Training was not always up to date.

People were not protected by the prevention and control of infection. Staff did not always receive adequate training and supervision.

People and their relatives told us they were treated with care and kindness. However, the care provided was not always person-centred.

Not all care plans contained enough information to ensure staff knew how to deliver appropriate person-centred care. People were not supported or enabled to take part in regular social activities that met their needs.

Staff were aware of who they were accountable to and understood their roles and responsibilities in ensuring people's needs were met. The registered manager had good links with a number of health and social care professionals and this helped to ensure people's needs were met.

Management and staff treated people with kindness and compassion. Positive relationships had developed between people and staff. However, people's experiences of care varied considerably.

The new management structure was committed to improving the service and creating a positive and inclusive culture at the service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published January 2020)

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on

the findings of this inspection.

We have found evidence that the provider needs to make improvements.

Enforcement and recommendations

We have identified breaches in relation to safe care and treatment, staffing, nutritional and hydration needs and good governance at this inspection and made a recommendation in relation to the Mental Capacity Act and care plans and risk assessments.

Please see the action we have told the provider to take at the end of this report.

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.

Follow up

We will request an action plan from 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 continue to monitor information we receive about the service, which will help inform when we inspect next.