Background to this inspection
Updated
24 November 2021
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 Care Act 2014.
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 was carried out by two inspectors.
Service and service type
Willow Park Lodge is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service did not have a manager registered with the Care Quality Commission. This means the provider is legally responsible for how the service is run and for the quality and safety of the care provided. There was a manager in post who had started the registration process.
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. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.
During the inspection
We spoke with three people who used the service and one relative about their experience of the care provided. We spoke with seven members of staff including the manager, quality manager, senior care workers, care workers and kitchen assistant. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.
We reviewed a range of records. This included six people’s care records and multiple medication records. We looked at two staff files in relation to recruitment. A variety of records relating to the management of the service, including checks and audits were reviewed.
After the inspection
We continued to seek clarification from the provider to validate evidence found.
Updated
24 November 2021
About the service
Willow Park Lodge is a residential care home providing personal and nursing care. The service can support up to 79 people in a purpose-built building. There are four floors of single room accommodation with en-suite facilities. At this inspection there were 32 people living at the service, six people living on the ground floor and 26 people on the first floor. No one was receiving nursing care.
People’s experience of using this service and what we found
People and relatives told us they felt safe living at the service. Since the last inspection the registered manager had left, the deputy manager had been promoted and was in the process of registering with the Care Quality Commission. The service continued to improve but further improvements were required.
Potential risks to people’s health, welfare and safety had been assessed. There was guidance in place for staff to mitigate the risks, however, some care plans required additional points to be personalised. Accidents and incidents had been recorded and analysed to identify patterns and trends.
Staffing levels were at the minimum to meet people’s needs and keep them safe. The manager continued to recruit care staff. New staff were being inducted during the inspection. Staff were recruited safely.
The service was clean, and staff followed infection control guidelines. Medicines were managed safely. Staff received training and their competency was checked before they administered medicines.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
People were treated with kindness and compassion. Staff supported people to be as independent as possible and be involved in making decisions about their care. People and relatives were invited to attend meetings to discuss the service and give their views. Staff attended regular meetings to discuss their practice.
Checks and audits had been completed on all areas of the service. When shortfalls had been identified, action had been taken to rectify them. The provider completed quality checks on the service and a service development plan had been produced, which the manager was using to make improvements. Complaints had been recorded, investigated and action taken if required.
People told us they received care and support in the way they preferred. People had access to activities they enjoyed.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 20 November 2020).
The provider completed an action plan after the inspection in February 2020 to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.
Why we inspected
This inspection was prompted by our data insight that assesses potential risks at services, concerns raised and based on the previous rating.
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.
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report covers our findings in relation to the breaches of regulation in Key Questions Effective, Caring and Responsive which contain those requirements. The Key Questions Effective, Caring and Responsive were inspected but not rated as not all the domain was covered.
The ratings from the previous comprehensive inspection for those key questions not rated on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained Requires Improvement. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Willow Park Lodge on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.