Willoughby Grange Care Home

Updated 13 October 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 team consisted of an inspection manager, an inspector 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

Willoughby Grange 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 had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the 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 reviewed information we had received about the service and sought feedback from the local authority. We used all of this information to plan our inspection.

During the inspection-

We spoke with three people who use the service, ten relatives, and a district nurse who was attending a virtual meeting at the service. We spoke with five members of staff including the registered manager, a nurse associate, two care staff and the executive chef. We reviewed a range of records including seven people’s care records. A variety of records relating to the management of the service were also reviewed.

After the inspection

We continued to seek clarification from the provider and registered manager to validate evidence found. We looked at training data and quality assurance records.

Updated 13 October 2021

About the service

Willoughby Grange Care Home is situated in the Lincolnshire town of Boston, providing accommodation over two floors, for people who require residential and nursing care. The service can support up to 39 older and younger adults, some of who may experience memory loss. At the time of the inspection there were 36 people living in the service.

People’s experience of using this service and what we found

People living at the service and their families told us that they felt safe living at Willoughby Grange.

People received care and support from staff who were caring and knowledgeable about their needs and preferences. People were positive about their experience of receiving care at the service. Systems and processes were in place to keep people safe. Staff were aware of how to identify and report signs of abuse, and when necessary the registered manager investigated and promoted learning from events. Staff received regular supervision and training to support them in their roles. People's nutritional and health needs were well managed.

We were assured that there were processes and policies in place related to infection control and prevention. However, there were parts of the service that needed redecoration, which would lead to those areas being difficult to keep clean. The provider and the registered manager had identified this during their audits and have an action plan in place regarding maintenance of the home. There were occasions during the inspection when staff had to be prompted by the registered manager to wear their PPE in the correct manner.

Peoples medicines were managed safely in line with their preferences. There were areas of the home which needed some maintenance, making it harder to keep these areas clean. The registered manager and provider had identified this in their own audits and a refurbishment plan is in place to address this.

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 trained staff deployed in the service to meet the needs of people living at the service. The registered manager continued to recruit staff to ensure people’s needs were met. The registered manager and provider carried out sufficient pre employment checks. The service worked with other health care professionals to maintain people’s health and well-being.

People at the service were treated with dignity and respect. People were encouraged to be involved in their care. Staff used the information they had gained from talking to people and their families to care for them in a person-centred manner.

We received feedback from relatives about the positive experience their relative had received at the end of their life, whilst being supported by the service.

There was a clear complaints process in place. There were robust systems and processes in place giving the registered manager oversight of the quality of the service. The registered manager promoted an open culture, with clear consistent leadership, staff felt supported in their roles.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

This service was registered with us on 4 June 2020 and this is the first inspection.

The last rating for the service under the previous provider was Good published on 19 March 2020.

Why we inspected

This was a planned inspection 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.

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.