31 October 2023
During an inspection looking at part of the service
People’s experience of using this service and what we found
We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.
Based on our review of key questions safe, effective and well-led, the provider was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.
Right Support: People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.
Right Care: People were at risk of harm because staff did not always have the information they needed to support people safely. Medicines were not always managed safely. People did not receive consistent person-centred care that was empowering, of a high-quality and achieved good outcomes.
Right Culture: Ethos, attitudes and behaviours of leaders and care staff did not fully ensure people using services led confident, inclusive, and empowered lives.
Infection prevention and control was not managed safely. There was a lack of timely action by leaders to ensure safeguarding incidents were responded to.
New starters were not trained in a timely manner. This meant they might not always be aware of current good practice. We have made a recommendation about this.
Premises were untidy and unclean. There was a lack of cleaning schedules in place.
People were not being supported to maintain a varied and healthy diet. We have made a recommendation about this.
Leadership was inconsistent. Governance systems were ineffective and did not identify the risks to the health, safety and well-being of people or actions for continuous improvements. Where the need for improvements had been identified, these had not been fully implemented. Records were not always complete. People and stakeholders were not always given the opportunity to feedback about care or the wider service.
The provider did not always submit notifications to CQC which is their legal responsibility to do so when certain significant events occur.
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 4 June 2020).
Why we inspected
The inspection was prompted in part due to concerns CQC received regarding a person using the service who sustained a serious injury. This matter is subject to further investigation by CQC. The information shared with CQC indicated potential concerns around the timeliness of seeking medical intervention. This inspection examined those risks.
As a result, we undertook a focused inspection to review the key questions of safe and well-led only, during the inspection we made the decision to look at the effective key question as well.
For the key questions caring and responsive not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Willow Brook on our website at www.cqc.org.uk.
Enforcement and Recommendations
We have identified breaches in relation to risk management including infection control and medicines, safeguarding, the Mental Capacity Act, maintaining suitable premises, governance and failure to notify CQC of significant events 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.
Follow up
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.
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures.’ This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.
For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it, and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.