Willow Brook

Updated 21 February 2024

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.

Inspection team

This inspection was carried out by 4 inspectors. Three inspectors were on site and 1 inspector made phone calls to staff.

Service and service type

Willow Brook is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under 1 contractual agreement dependent on their registration with us. Willow Brook is a care home without 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 not a registered manager in post. A manager had recently been appointed. They are in the process of applying to become the registered manager.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We observed interactions between staff and people in communal areas of the service to help us understand the experience of people who could not talk with us. We reviewed a range of records including 3 people’s care records and 3 people’s medicines records. We looked at 4 staff files in relation to recruitment. We spoke with 8 members of staff including the care director, the manager, the deputy manager and 5 care workers. We received email feedback from 3 professionals and 2 relatives.

Updated 21 February 2024

Willow Brook is a residential care home providing accommodation for up to 5 people who require nursing or personal care. The service provides support to people with learning disabilities, mental health, and complex needs. At the start of our inspection there were 3 people using the service. The care home accommodates 5 people on the ground floor of 1 adapted building.

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

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Based on our review of key questions safe, effective and well-led, the provider was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

Right Support: People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Right Care: People were at risk of harm because staff did not always have the information they needed to support people safely. Medicines were not always managed safely. People did not receive consistent person-centred care that was empowering, of a high-quality and achieved good outcomes.

Right Culture: Ethos, attitudes and behaviours of leaders and care staff did not fully ensure people using services led confident, inclusive, and empowered lives.

Infection prevention and control was not managed safely. There was a lack of timely action by leaders to ensure safeguarding incidents were responded to.

New starters were not trained in a timely manner. This meant they might not always be aware of current good practice. We have made a recommendation about this.

Premises were untidy and unclean. There was a lack of cleaning schedules in place.

People were not being supported to maintain a varied and healthy diet. We have made a recommendation about this.

Leadership was inconsistent. Governance systems were ineffective and did not identify the risks to the health, safety and well-being of people or actions for continuous improvements. Where the need for improvements had been identified, these had not been fully implemented. Records were not always complete. People and stakeholders were not always given the opportunity to feedback about care or the wider service.

The provider did not always submit notifications to CQC which is their legal responsibility to do so when certain significant events occur.

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 4 June 2020).

Why we inspected

The inspection was prompted in part due to concerns CQC received regarding a person using the service who sustained a serious injury. This matter is subject to further investigation by CQC. The information shared with CQC indicated potential concerns around the timeliness of seeking medical intervention. This inspection examined those risks.

As a result, we undertook a focused inspection to review the key questions of safe and well-led only, during the inspection we made the decision to look at the effective key question as well.

For the key questions caring and responsive not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Willow Brook on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to risk management including infection control and medicines, safeguarding, the Mental Capacity Act, maintaining suitable premises, governance and failure to notify CQC of significant events at this inspection.

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 next inspect.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures.’ This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it, and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.