Willowbrook View

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• 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 service. This key question has been rated good.

This meant people were safe and protected from avoidable harm.

This service scored 84 (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 strong proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

People and their relatives told us they were regularly invited to share their views through open-door access to leaders, meetings and structured surveys, and consistently felt listened to.

There was a well-established approach to learning from incidents and events, particularly in relation to falls. Each fall was thoroughly analysed, with clear root cause analysis and individual interventions implemented to reduce the risk of reoccurrence. Learning was further strengthened through quarterly falls forums, where staff and leaders shared data, identified themes, discussed lessons learned and exchanged effective interventions with other services. This collaborative approach enabled best practice to be shared across the organisation. We saw improved safety for people with a reduction in falls where people had sustained a serious injury.

The provider actively responded to feedback by introducing solutions to enhance care delivery. For example, a new call bell system was implemented following staff feedback about the limitations of the previous system. Staff reported the new system significantly improved their ability to respond quickly and effectively to people’s needs, enhancing both safety and responsiveness.

In addition, the provider had introduced an acoustic monitoring system, designed to detect, analyse and track sound patterns to alert staff to potential concerns within the environment. At the time of assessment, this system was being embedded into practice.

We saw further evidence of a proactive and embedded learning culture through regular team meetings, supervisions, reflective discussions and risk management forums where staff explored values, behaviours and learning opportunities. Staff were encouraged to raise safety concerns, which were taken seriously, thoroughly investigated and used as learning opportunities to improve practice.

The provider always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services.

The provider had a specialised system in place to support people who required hospital admission during the night. A staff member always accompanied the person until a family member was able to attend. Where family support was not immediately available, staff remained with the person until they were safely admitted to a ward. Staff took responsibility for coordinating the person’s care needs and ensured hospital staff received all relevant and up‑to‑date information. This approach meant people and their relatives felt reassured, the person was supported by a familiar face, and they felt confident that clinicians had a full understanding of their needs. A family member who benefitted from this intervention said it had given them reassurance when the staff member was with their relative in the hospital. A dedicated rota ensured staff were consistently available to support hospital visits, with senior management providing additional support where required.

People and their relatives told us transitions into and out of the home were managed extremely well. One relative told us, “We had an initial family meeting before [Person] went into the home and a review. It was very good communication.” There were several examples of people who had come into the home for short term respite who stayed for longer durations with some staying permanently.

A partner provider described how the service successfully supported a person whose needs had not been met elsewhere. Since moving to the service, the person had settled well due to staff developing a clear understanding of triggers and behaviours and adapting care, accordingly. This was completed by working in collaboration with partners, staff and family members.

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. The provider shared concerns quickly and appropriately.

People and their relatives consistently told us they felt safe using the service. Staff and leaders demonstrated an understanding of their safeguarding responsibilities and were confident in how to raise a concern. Staff clearly described the different types of abuse, the signs to look out for, and the correct escalation procedures. They were also knowledgeable about external agencies and when to involve them.

Safeguarding documentation was well organised, up to date, and accurately reflected actions taken. Concerns were escalated appropriately through relevant partners, and we saw evidence of reflective practice with staff following safeguarding concerns. People and their relatives were kept informed, demonstrating a transparent approach.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. The provider was able to identify when people were potentially being deprived of their liberty, complied with the principles of the Act, and made applications or/and urgent authorisations in a timely manner.

Staff had received training in safeguarding, MCA and DoLS.

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.

People and their relatives told us that staff understood people’s individual risks. We observed people being encouraged to take positive risks, with staff providing the right level of supervision, monitoring, and intervention when needed.

Care plans and risk assessments contained sufficient information to guide staff in supporting people safely. People, their relatives, and relevant partners were involved in the development and review of care plans and risk assessments. The provider also made effective use of technology to support risk management, including call bells and under‑bed sensor alarms.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

We observed people had access to various equipment to keep them safe such as wheelchairs, walking frames and equipment to support mobilising. When staff used equipment to support people, they explained what was happening to ensure the person felt safe before a transfer. Staff were knowledgeable about the fire evacuation procedures and had received training.

Safety checks had been completed by external contractors and there was evidence of regular on-site maintenance checks. We saw window restrictors were in place to prevent the risk of falling from heights, and wardrobes were integrated into people’s rooms to prevent the risk of falling on people. Door codes were in place to protect people where required and the gardens were well maintained and secure for people to access.

The business continuity plan identified what to do in an emergency.

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.

People and their relatives told us staff responded promptly when support was requested, and staff were approachable and attentive to people’s needs. One person commented, “I can’t praise the staff enough, honestly, they are one of the best things out of an already brilliant home.”

The provider had safe recruitment practices in place, in line with organisational policy and relevant legislation. Staff records showed appropriate pre-employment checks had been completed. Staff received regular supervision and annual appraisals, including night staff, to support their development and wellbeing. The provider’s supervisions and appraisals were called ‘Extraordinary conversations’ and included topics such as wellbeing and engagement, day-to-day performance and practice, learning, confidence, and development and forward planning and goal setting. Additional reflective practice sessions were also arranged.

Staff told us they had access to training relevant to their roles and felt supported by the provider to undertake additional qualifications when required or requested. We saw evidence of opportunities for professional development, including pathways to support staff progression and the development of future leaders.

Staffing rotas and dependency tools demonstrated the service was operating approximately 5% above the recommended staffing levels according to their staffing dependency tool. This tool is used by provider to assess the level of staff needed based on people living in the service. Leaders told us this was a deliberate approach to ensure people’s needs were met and to support staff wellbeing.

During the day, the deputy manager was available to provide additional support across the home, and an on-call management system operated overnight. Staff told us that when they contacted the on-call system, managers responded promptly and provided the support required.

The provider thoroughly assessed and managed the risk of infection. They always quickly detected and controlled the risk of it spreading and always shared concerns with appropriate agencies promptly.

Arrangements were in place to minimise the risk of cross‑infection. For example, kitchen staff uniforms were laundered on site. This helped ensure appropriate infection control standards were maintained and reduced the risk of external contamination.

People and their relatives spoke positively about the cleanliness of the service and how it contributed to people’s overall well-being. One person told us, "It is spotless and unbelievably clean," while another said, "Housekeeping always keeps it immaculate." These comments reflected what we saw during the assessment during both site visits; we consistently found the environment to be exceptionally clean, well-organised and free from odours.

Staff were observed following effective infection prevention and control (IPC) practices. This included appropriate hand hygiene and the correct use of personal protective equipment (PPE). PPE was readily available in all relevant areas, supporting staff to implement IPC measures in line with best practice. Staff across all roles showed an understanding of their responsibilities in relation to IPC and demonstrated pride in maintaining a safe, hygienic environment for people.

All equipment, furnishings and frequently touched surfaces were clean and well maintained, reducing the risk of infection. The service had clear cleaning schedules in place, which demonstrated regular and thorough cleaning of all areas, including people’s bedrooms and communal spaces.

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.

People and their relatives told us medicines were provided safely.

Medicines administration was observed to be safe, person‑centred, and well organised. Staff demonstrated good knowledge of people’s needs, including time‑critical medicines, preferences, and safe administration practices. Staff received medicines training appropriate to their role, with competency assessments completed regularly.

Medicines admission and ordering processes were established and consistently applied with residents having a minimum of two weeks supply available. Medicines were checked, booked in, and signed for by 2 staff members. Medicines errors were reported promptly, investigated, and analysed, with learning shared to support improvement. We could not see any harm had come to people due to the medicines errors reported.

The electronic Medicines Administration Record (eMAR) system supported safe practice through alerts, prompts, and clear administration schedules. People’s records demonstrate that medical histories, allergies and personal preferences, were documented.

Medicines rooms were secure, temperature monitoring was maintained, and medicines that needed specific storage were managed.

However, we identified some ‘as and when’ PRN guidelines lacked sufficient detail, including clear indications for use and guidance on when dose escalation was appropriate. Risk assessments for anticoagulant medicines were not always available. There was no evidence of harm to people, and the provider updated the documentation on the day of the site visit.