Willows Lodge Care 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. We assessed a total of 7 quality statements from this key question. We have combined the scores for these areas with scores based on the rating from the last inspection, which was requires improvement. At this assessment this key question has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff knew how to record accidents and incidents. However, a health professional told us these were not always reported in a timely manner. Staff told us, “I would document any accident or incident and then inform the home manager.”

The registered manager had been engaging with the local authority to make improvements at the service to support better outcomes for people. The service had regular visits from the local authority who had helped to facilitate learning and improvements at the service. There were systems in place to record incidents and accidents which were reported by staff. The registered manager reviewed incidents to identify where actions where needed but some care plans and risk assessments were not always updated accordingly. There was no formal record of lessons learnt following accidents and incidents. The registered manager completed a monthly audit for accidents and incidents and identified themes and trends. However, there was no further outcome identified following the analysis.

A person told us, “I do feel safe, I trust the people looking after me, they are kind and they do listen.” However, another person told us, there had been occasions where they have had to wait a few hours before they received any support. Another person who required regular support with personal care told us they don't often receive it in a timely manner. Another person told us, “I feel like complaining but I don’t, they might take it out on me.”

Staff understood how to recognise the signs of abuse and could describe the actions they would take to safeguard people including informing other agencies if they were concerned about action being taken. A staff member told us, “I would report to my manager, and I would escalate to Local authority if I needed to”. However, some staff told us that they felt short staffed and couldn’t always get to people in a timely manner. Another staff member told us, “Another pair of hands would be useful.”

Staff supported people to move safely using assessed equipment where required. However, during the assessment, we observed periods of time where staff were unavailable to support people promptly. There was often times during the day where people who were at high risk of falls were left unsupervised in communal areas.

Safeguarding systems were in place to safeguard people from abuse. The provider had safeguarding policies and procedures in place and had a procedure for ‘whistleblowing’. Records we looked at showed when safeguarding incidents had occurred, the registered manager had reported these to the relevant safeguarding authority for investigation and notified CQC as is required by law. This meant people were protected from the risk of harm or abuse. The registered manager told us they shared information with staff in meetings to learn from any incidents. However, as per the training matrix, not all staff had completed their training in abuse awareness.

Most relatives told us they felt involved in their relatives’ care. A relative told us, “We can see [relative’s] care plan its available to us at all times, they have a yearly review anyway and we were involved as the care plan changes as [relative’s] needs change." However, not all relatives had seen or been involved in writing their care plans. A relative told us, “I haven’t seen the care plan and I have never been invited for a review.”

Staff had a good understanding of people's risks and how to safely support them. Staff had received training to support people safely. However, not all staff had completed their mandatory training as per the training records. Staff told us, “I know how to look after everyone here. I do my best but there are times where we are really busy so I can’t always get to someone as soon as the buzzer goes off.”

Throughout the on site assessment, we observed people being supported to move using mobility equipment and this was done safely. A person was using a walking frame to enter the dining room and staff supported them and were responsive to any potential risks. However, we observed people in a communal lounge needed support with their Zimmer frame, but they were left unattended for a period of time and there were no staff members available to assist them.

Not all risks to people's safety and wellbeing were assessed, recorded or provided enough detail to about how risks should be managed and mitigated as far as possible. Records did not demonstrate potential risks to people's safety were always or appropriately assessed and delivered in a safe way. Their care plans and risk assessments were not always personalised, and support was not always in line with people's care plan guidance. Some information was generic and not personalised to the individual people using the service. Whilst repositioning charts were being completed on the electronic system, they did not always show that 2 hourly turns were completed in line with risk assessment requirements. A catheter care plan lacked detail to ensure the required support was being given, to monitor urine for signs of infection or positioning of the catheter bag. Risks relating to the service's fire arrangements were monitored and included individual Personal Emergency Evacuation Plans [PEEP] for people using the service. However, some of the information was not accurate or up to date. For example, a person’s PEEP stated their bedroom was on the first floor, but it was actually on the 2nd floor. Systems had not been established to ensure care and treatment was provided in a safe way for service users. This placed people at risk of harm. This was a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Staff told us they felt the environment well maintained and staff had access to the equipment they needed to support people safely. However, a staff member told us, “Another pair of hands would be useful. Staff are very helpful moving people, the big room upstairs can take 17 but if we use the table, it takes 14. We had a big party there with some people standing and had 30 but if it’s only me in the room I have to press the buzzer.”

Generally, the environment was well maintained, and staff had access to the equipment they needed to support people safely. However, we found the paving in the garden was uneven and needed replacing. The registered manager told us they had plans in place for this to be addressed. Uneven flooring was found between some of the bedrooms. Following the on site visit, the registered manager implemented an additional grab rail and hazard tape to inform people of the change in floor levels. Uneven flooring poses a serious risk of slips, trips, stumbles and falls.

The provider employed maintenance staff to ensure the premises were well-maintained and safe. There were systems in place to ensure any maintenance needed was responded to promptly. We saw records of checks that had been carried out on equipment and the premises. However, we found some wardrobes were not affixed to walls in people's bedrooms. This meant there was a potential risk for wardrobes to topple over onto service users causing crush injuries.

During the on-site part of this assessment we observed some vulnerable people were left alone as there were no staff in communal areas. The views of people using the service and others, who had an important part in their lives, were varied, but did highlight there were, on occasions, insufficient staff available to meet people's needs. Comments included, “There is not enough staff, only 2 or 3 of them for all of us, today there were only 2 at breakfast, sometimes you wait for a half an hour, not always at the same time for someone to come, weekends are about the same as weekdays, breakfast times the staff are here there and everywhere”. Another told us, “You can not always get in on the weekends, you have to wait for staff.” One commented, “The front door that is the only thing they could do better on, at weekends the waiting to get in is long, they need a camera there and a button to open the door – you can be stood there 10 minutes plus”.

Staff told us there had been a lot of improvements since the last inspection and they felt supported by the registered manager. A member of staff told us, “Things have definitely improved since you [CQC] were last here. The manager is amazing and very approachable. Things are very settled, but we could just do with some extra staff, so we have time to get round to everyone.” However, another staff member told us, “We very rarely get time to stop and talk to the residents. We literally are in and out after completing tasks so we can get to the next person.” The operations manager told us they were keeping staffing levels under constant review. The service had recently appointed a clinical lead and deputy manager to support the units.

However, during the on site assessment, we observed periods of time where staff were unavailable to support people promptly. There was often times during the day where people who were at high risk of falls were left unsupervised in communal areas. We observed call bells were buzzing for approximately 9 minutes before staff were able to get to the person. We observed staff to be task focused and there were not always enough staff available to provide prompt support on the day of our visit.

There was variable feedback around staffing levels. Systems and processes did not demonstrate how the service ensured there were enough suitably trained and experienced staff at all times. Limited information was available on staff files to demonstrate a robust induction had been completed to enable staff to carry out their role and responsibilities effectively. Not all staff received regular support in the form of a supervision. Some staff told us they did not have regular supervisions and this information concurred with the home's supervision records. The Operation's Director had identified these shortfall's during their audit however, no action had been taken. This meant there were no effective arrangements in place to monitor staffs' practice, performance and professional practice. Although there was no impact for people using the service, staff training records showed not all staff employed at the service had received all mandatory or refresher training. Suitable arrangements were not in place to ensure all staff employed received appropriate training, a robust induction or regular supervision. This was a breach of Regulation 18 [Staffing] of the Health and Social Care Act 2008 [Regulated Activities] Regulations 2014. The registered manager had not always ensured staff were safely recruited. Relevant recruitment checks were not always completed before staff started work. We saw gaps in recruitment files, such as some staff did not have completed references on file and not all references received had been verified. For 1 member of staff, the offer of employment letter was received before the interview date. The registered manager had not completed the appropriate checks to ensure that staff were recruited safely into the service. This demonstrated a breach of Regulation 19 [Fit and proper persons employed] of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Staff confirmed they received infection prevention and control (IPC) training and felt confident to support people with their personal care. However, not all staff had completed their Infection prevention and control training as per the services training matrix. Staff we spoke to told us that there was sufficient personal protective equipment (PPE). Following the on site visit, the registered manager confirmed all staff members had completed their training.

Staff had personal protection equipment situated throughout the service giving them easy access to wear when needed. The service was mostly clean and tidy with no odours. However, we found the kitchen floors, kitchen cupboards and dining room needed a deep clean. Some of the toilets also needed thorough cleaning.

The registered manager carried out daily spot checks and completed regular audits to monitor the cleanliness of the service. However, the audits lacked detail and the information recorded on the audit did not have any dates for actions to be completed and there were no outcomes recorded. Details of who the actions needed to be completed by were also not recorded. The daily audits did not identify the shortfalls found on this assessment.

People usually received their medicines safely. However, on the day of the on site assessment, the morning medicines administration round finished at approximately 12 noon on 2 floor's. This increased the risk of people not getting their medicines as prescribed especially medicines to be administered three or four times daily such as antibiotics. People’s care plans were not always up to date or reflective of their care needs. Care plans for specific conditions did not contain person centred information.

Staff were trained to ensure that medicines were used safely and effectively. This included routine competency checks and training with specific medicines for all staff such as midazolam as a rescue medicine for seizures. Staff we spoke to were knowledgeable about the people in the service and their medicines needs. Staff told us that the GP visits the home weekly as well as when needed to review patients.

There were processes in place to ensure that people received medicines safely. This was supported by an electronic medicines administration record (e-MAR). However, we observed that medicines administration rounds took a long time to be completed. Staff stored medicines safely in locked fridges and cupboards, however we observed that fridge temperatures were outside the recommended parameters. Medicines risk assessments were not regularly reviewed or updated and people on high-risk medicine did not always have the appropriate medicines risk assessment in place. This could impact on how well a person’s condition was managed. We saw one incident where the Controlled drugs balance appeared not to be accounted for, we later found out that this was due to inappropriate documentation.