24 June 2023
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.
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.
This inspection was undertaken by 2 inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
Willow Lodge is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Willow Lodge is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
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 a registered manager in post.
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 (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used information gathered as part of monitoring activity that took place on 14 February 2023 to help plan the inspection and inform our judgements. We used all this information to plan our inspection.
During the inspection
We spoke with 9 people who used the service and 2 relatives about their experiences of the care provided. We spoke with 7 members of staff including the registered manager, deputy manager, head of care, care staff and ancillary staff. We reviewed a range of records. This included 8 people's care records and multiple medication records. We looked at 3 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
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.
24 June 2023
About the service
Willow Lodge Care Home is a residential care home providing the regulated activity of accommodation with personal care for up to 40 people. People had a range of care needs including frailty of age, Parkinson’s disease, people living with dementia and people with a learning disability. At the time of our inspection there were 38 people using the service. Accommodation was over three floors in one adapted building or in purpose built garden lodges.
People’s experience of using this service and what we found
People did not always receive safe support with their medicines. People told us they felt safe. A person told us, “I feel safe here and that’s important”. Relatives had no concerns about their loved one’s safety. Systems were in place to protect people from the risk of abuse and improper treatment. Staff knew how to identify potential harm and report concerns. Risks were identified and managed.
Systems and process were in place to monitor the quality of the service being delivered. These had not been effective in providing management oversight of medicines. The culture of the service was positive, and people and staff were complementary of the registered manager and provider. 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.
There were enough staff to meet people’s needs in a timely and person-centred way. Care plans provided detailed information and guidance for staff. Staff knew people well and provided support in line with people's preferences. People and relatives told us the care people received was very good and the staff were kind, caring and compassionate.
We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence, and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.
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 12 February 2021).
Why we inspected
The inspection was prompted in part due to concerns around the management of medicines and a notification of a serious incident. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk of medicines.
As a result, we undertook a focused inspection to review the key questions of safe, responsive, and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.
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.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Willow Lodge Care Home on our website at www.cqc.org.uk.
We have identified breaches in relation to the management of medicines 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.
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.