Willow Lodge Nursing 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.

At our last assessment, we rated this key question as good. At this assessment, the rating has remained as 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.

People and staff were supported to raise and report safety concerns and events. Senior staff investigated these and made sure appropriate actions were taken in response.

Concerns and events were reviewed and analysed to identify trends, themes, and opportunities for learning across the service. This learning was shared with staff to support improvements in working practices and help keep people safe. The registered manager told us, “I do a monthly audit of all accidents and incidents, and I use this to speak to staff to give them a summary of what’s happened and any actions required.”

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.

Systems were in place to ensure people received safe and appropriate care as soon as they started using the service. Prior to moving in, assessments were completed with people and their representatives to identify their needs, preferences, and risks to their safety and wellbeing. Information was also gathered from healthcare professionals involved in people’s care to provide a comprehensive overview of their healthcare and support needs. This information informed people’s care plans and risk assessments, which were shared with staff prior to the commencement of care and support to people. A staff member told us, “When the registered manager does an assessment, she will come back and tell us all about the person and what they need, before they come.” Another staff member said, “Whenever a new person comes in, the manager will let us know what they need and we read the care plans that are put in place.”

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 were safe at the service. A relative told us, “I think [family member] is safe here and well cared for. There hasn’t been anything to concern me.” A healthcare professional told us, “There is a real focus on treating people with dignity and respect and ensuring they feel safe, comfortable and well cared for.”

Staff received training to safeguard people from abuse and were supported to raise and report concerns when needed. A staff member told us, “The [registered manager] is always checking our understanding, especially at staff meetings. We talk about safeguarding all the time. I feel comfortable looking out for signs of abuse and I would tell the manager straight away.”

Senior staff made timely safeguarding referrals when required and worked with the relevant healthcare professionals to ensure people were safeguarded from further risk.

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. We found that appropriate legal authorisations were in place to deprive people of their liberty where this was deemed necessary to ensure their safety.

Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were supported to stay safe and spend their time as they wished at the home, without unnecessary restrictions. A person told us, “There’s no locked doors around the home.” A friend of a person using the service said, “[Person] is quite safe and [staff] are managing risks to her safety.”

Staff were present, vigilant and available to assist people when required. Staff understood how risks to people should be managed to keep them safe. We observed staff using equipment safely and appropriately when supporting people to move and transfer around the environment. The staff team worked well together across all shifts to ensure risks to people were managed effectively. The registered nurse said, “During night shifts we work well together with moving and handling, hoisting and positioning people.”

Senior staff reviewed people’s records at regular intervals to ensure they contained current information about risks to their safety and how these should be managed to keep them safe from harm.

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

The provider undertook environmental risk assessments to identify potential risks and hazards. Plans were in place to manage risks associated with the environment. These were regularly monitored and reviewed by senior staff to ensure they remained current, effective and reflective of people’s needs at the service.

Safety systems and equipment were maintained and serviced in line with requirements to ensure they remained safe and fit for purpose.

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 were supported by enough appropriately skilled staff who understood how to meet their needs. A staff member told us, “The staff team works well together. [Registered manager] will match the team together well. She plans the rota based on people’s needs. The staff are happy here. There are enough staff here.”

Staff undertook regular and relevant training to help them meet people’s needs. Senior staff supported them to continuously develop and improve in their roles through supervision and appraisal of their work performance. A staff member told us, “[Registered manager] is very good at helping us with learning and development and talked to me about doing Level 3 (Diploma in Adult Care).”

The provider undertook robust recruitment checks on staff who applied to work at the service to make sure they were suitable to support people. This included criminal records and right to work checks. Staff completed an annual self-declaration to confirm that the information held by the provider remained accurate and that there had been no changes to their circumstances that would affect their suitability to work with people.

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.

People lived in a clean and hygienic environment that was free from malodour. The provider employed a dedicated housekeeper who we observed during our visits cleaning communal areas and people’s rooms, ensuring these were kept clean and tidy. A person told us, “They do the cleaning every day. I gave the laundry lady my rug this morning to clean and it’s been washed. I gave them my laundry, and it all comes back to me clean and folded.”

Staff received relevant training and had access to personal protective equipment (PPE) and other supplies to help minimise the risk of infection. The chef maintained clear and up-to-date records relating to food safety. Food items stored in fridges, freezers and the ambient store cupboard were clearly labelled and within their use-by dates.

Senior staff undertook checks and audits to ensure staff working practices were in line with relevant standards and national guidance for managing and minimising infection risks.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

People consistently received their prescribed medicines. Our checks of medicines stocks and records confirmed this.

Staff were provided with relevant training to manage and administer medicines to people. People’s records contained key information about the support they required to take their medicines. This included guidance for staff administering ‘as required’ (PRN) medicines about how people might communicate or present a need for these medicines. Some people received their medicines covertly. Senior staff ensured the appropriate authorisations were in place to support this.

People’s medicines were reviewed by relevant healthcare professionals at regular intervals. Senior staff worked closely with them and provided relevant information about people to support professionals in their decision making. The registered manager told us this had led to a reduction in the use of antipsychotic medicine for one person, alongside improvements in the person’s behaviour.

Senior staff undertook regular checks and audits, including competency assessments, to ensure staff managed and administered medicines safely.