23 July 2021
During an inspection looking at part of the service
Willow Grange Nursing Home is a residential care home providing personal and nursing care for up to 44 people. At the time of inspection, 29 people were using the service, some of whom were living with dementia.
People’s experience of using this service and what we found
Risks to people’s health were not always identified and managed. Medicines were not always managed well. The medicines policy was not up to date and did not provide sufficient guidance to staff. Staff understood how to identify and report abuse. People were protected from the risk of infection.
Staff required more support in their supervisions. Staff received training to enhance their knowledge. People had access to sufficient food and drink.
Relatives told us that sometimes staff were not always kind and caring. Staff did not always deliver care in a manner that respected people’s dignity and privacy. People were supported to maintain their independence.
Care records were not always consistent and a reflection of people’s needs. There was no registered manager at the service. The provider did not always engage with stakeholders to drive improvement. Lessons were not drawn from incidents that happened at the service to improve the quality of care. Audits had not identified the issues we found during the inspection.
People who used the service and their relatives knew how to make a complaint or raise concerns about the care provided.
We were assured the provider was working within current guidance on good infection prevention and control guidelines in relation to the COVID-19 pandemic. Risk management plans mitigated risks in relation to COVID-19 pandemic and spreading of infections. Staff followed guidance to respond to COVID-19 and other infection outbreaks effectively. Staff had access to sufficient Personal Protective Equipment and used it appropriately. Visitors underwent COVID-19 checks to minimise the risk of spreading of infection.
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 Good (published 3 December 2019). The service is now rated requires improvement.
This report only covers our findings in relation to the key questions; Is the service Safe, Effective, Caring and Well-led.
Why we inspected
We received concerns in relation to concerns about people’s wishes not being respected, learning from incidents and management of the home. As a result, we undertook a focused inspection to review the key questions of safe, caring and well-led only.
We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.
We also 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. As we did not look at the entire key question of Safe the rating for the Safe key question has not been changed.
Full information about CQC's regulatory response to the concerns found during inspections is added to reports after any representations and appeals have been concluded.
During this inspection we found breaches in relation to condition of registration of a registered manager, dignity and respect and good governance
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified breaches in relation to respect and dignity and good governance at this inspection.
Follow up
We will request an action plan for 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 return to visit as per our inspection programme. If we receive any concerning information we may inspect sooner.