Willowbrook View

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This is the first assessment for this service. This key question has been rated good.

This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

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 made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

People and their relatives told us reviews of needs was completed regularly. We saw evidence of people’s relatives being invited to attend monthly meetings to discuss and review care plans.

Comprehensive assessments were completed prior to admission and reviewed again on arrival to ensure continuity and accuracy of information. People’s needs were reviewed regularly, with care records updated to reflect any changes.

Staff told us they reviewed people’s information thoroughly before admission to ensure they had a clear and detailed understanding of each person’s support needs. We also saw evidence of external partners, including healthcare professionals, being involved in the assessment process where required.

The provider did not always have current evidence-based good practice standards or guidance embedded into their care plans.

We identified inconsistencies in care records. For example, one person’s documentation contained conflicting information regarding their Body Mass Index (BMI). One record indicated the person was underweight, while another stated their BMI was within a normal range. In addition, the person’s ‘Waterlow’ score, which is a tool used to assess the risk of pressure damage, differed between two documents. These discrepancies meant staff could not be assured they were working with accurate and reliable information to inform care delivery.

We also saw specific guidance relating to a person’s diagnosed medical condition was not clearly recorded. Key signs and symptoms to monitor and escalate had not been completed to guide staff in providing safe and appropriate care.

There was no evidence that these concerns had resulted in harm. The provider responded promptly to our feedback and took immediate action to update and improve documentation during the assessment.

However, most care plans reviewed reflected current best practice, with national guidance and recognised assessment tools being used. The service had established ‘champion’ roles in areas such as dementia and end-of-life care. Staff were receiving specialist in-house dementia training as part of a wider dementia care strategy.

The provider worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff and leaders worked collaboratively with visiting professionals. Records showed people had access to GPs, district nurses and other healthcare professionals as required. People also confirmed they received regular support to meet their health needs.

One visiting GP told us, “Clear and up-to-date information is always provided when reviewing care plans, and the information supports understanding and assessment of people’s needs. The handovers are very good.”

Leaders and staff demonstrated good knowledge of external services available to support people and made appropriate referrals when needed. The service had also integrated additional support, including access to an on-site physiotherapist, to help meet people’s mobility and rehabilitation needs.

The provider always supported people to manage their health and wellbeing to fully maximise their independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support.

People experienced a highly responsive and person-centred approach to nutrition. A dedicated catering team worked closely with people to ensure they could access the food they wanted. Menus had been co-produced and recently reviewed, reflecting people’s preferences and choices. The chef built positive relationships with people, taking time to understand their individual likes, dislikes and dietary requirements, which were clearly communicated.

People were not limited to menu choices and could request meals at any time, which were freshly prepared for them. An on-site bistro further enhanced people’s experience, offering freshly prepared drinks, cakes, fruit and snacks for both people and their relatives. Feedback was overwhelmingly positive, with people consistently praising the quality and variety of the food.

The service provided proactive and preventative healthcare support, including access to an on-site physiotherapist who supported people with regular strengthening exercises. A structured falls prevention programme helped people understand and reduce risks, promoting confidence and safety. We saw multiple examples where people’s mobility had improved through targeted interventions, leading to greater independence. One relative told us, “The physiotherapy has been brilliant. They have made [Person’s name] into how well they are now. They are walking again after only a few weeks.”

The service’s on-site gym was well used, and we observed a physiotherapy-led session that was engaging, inclusive and motivating, encouraging people to remain active and maintain their independence.

One professional commented, “The staff are quite familiar with their clients and are able to identify risks to people’s health and well-being early to avoid any deterioration.”

The provider routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Monitoring systems were fully embedded within the care planning process, enabling the provider to effectively track and measure people’s outcomes. Clear, defined tasks were in place for staff to complete and record, ensuring oversight.

For people living with dementia, behaviours were closely observed to identify any changes or escalation, allowing staff to recognise potential triggers and implement timely and appropriate interventions.

There were several examples where effective monitoring had led to improved outcomes for people. For instance, staff recognised when a person was not presenting as their usual self and promptly contacted the GP, raising concerns about a possible urinary tract infection (UTI). Following assessment, the GP prescribed antibiotics, which helped prevent further deterioration.

One person told us, “They are always keeping an eye on me to make sure everything is alright.”

However, we found inconsistencies in one person’s fluid monitoring records. We reviewed documentation over a 5 day period, which showed that on 2 days the person had not been offered their assessed daily fluid intake and had consumedless than the amount recommended in their care plan. This meant there was a risk the person’s hydration needs were not being consistently met, and staff could not be assured that accurate monitoring and recording of fluid intake was taking place. A member of the management team told us they would review the person’s fluid intake, update the relevant documentation, and communicate with staff regarding the accurate recording of fluids offered and consumed. The provider subsequently provided evidence of this being completed.

The provider told people about their rights around consent and respected these when delivering person-centred care and treatment.

People told us staff asked for their consent when they required support with personal care. Staff understood about gaining consent from people and we observed staff asking people for ongoing consent.

The provider had systems and processes that ensured the Mental Capacity Act 2005 (MCA) was followed to support people who lacked capacity to make specific decisions. Mental capacity assessments and best interest decisions were completed to ensure decisions made on behalf of people were made lawfully. Consent preferences were clearly documented in people’s plans.