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. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm. The provider was previously in breach of the legal regulation in relation to safeguarding, safe care and treatment and safe and effective staffing. Improvements were found at this assessment and the provider was no longer in breach of this regulation.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. The registered manager shared learning with staff from incidents, accidents, complaints and safeguarding incidents so the service could continually improve and develop positive outcomes for people. Information was shared with staff during handovers, supervisions and meetings. Staff reflected on learning from these and worked on embedding good practice to keep people safe. A member of staff told us, “There have been a lot of changes recently and we are all working hard to make improvements. The daily stand up meetings are really helpful as we are always kept fully informed, and the manager is also aware of everything that is happening within the home.”

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. Before people moved to Willows Lodge Care home the registered manager completed an assessment of their needs to ensure they could be met by the service. As part of the transition, people and their relatives were able to visit the service. Staff told us they read through the care plans to ensure they had all the information they needed to provide support safely. A relative told us, “[Relative] has just arrived today, and we would like to say how impressed we are with the welcome here. We have paperwork to complete about [relative’s] likes and dislikes.” A health professional told us, “The home accepts admissions, allowing time between individuals moving in. This enables them to create care plans and risk assessments in a timely and safer manner.”

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately. The registered manager had raised safeguarding concerns appropriately and had worked with the local authority to investigate these, ensuring people were protected from harm and that appropriate actions were taken to address any risks identified. Staff had received training in safeguarding and knew how to raise concerns. A member of staff told us, ''I know how to report any form of abuse, and I would take immediate action. I would know who to report to and I would continue to escalate further to the Local Authority if I needed to.'' Staff were able to recognise when people were experiencing emotional distress and knew how to support them. For example, a member of staff told us they would know what to say and how to manage a person's distress when they became anxious.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled them to do the things that mattered to them. People were involved in planning their care and managing risks. Care plan and risk assessments were person centred and aimed to provide positive outcomes for people whilst maintaining their choice and independence. However, some relatives told us they had not been involved in care plan reviews. The registered manager told us a relatives meeting had been arranged to discuss care reviews.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The environment was adapted to meet the needs of people living there. There were spacious living areas offering people plenty of room to relax and engage in activities comfortably. Additionally, people had access to outdoor spaces, providing an opportunity to enjoy fresh air and relax in the gardens. People had their own rooms and specialist equipment was provided as needed. Maintenance staff were employed to ensure the premises were well-maintained and safe. There were systems in place to ensure any maintenance needed was recorded and responded to promptly. Records of checks on equipment and the premises were up to date.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care that met people’s individual needs. The registered manager had processes in place to ensure all staff received an induction. The operations manager had introduced a new induction template, since the previous inspection, and staff we spoke with told us they had an extensive induction. However, we received variable feedback from people and relatives. Several relatives told us they felt the staffing levels reduced on the weekend and there was a lot of agency staff being used. A relative told us, “They seem to have sufficient staff in the week, but it is different at weekends. They seem short and you struggle to actually get into the home at weekends. You will wait ages to be let in so that must be impacting on the residents although I can’t give any examples. You never see any of the management team in at weekends. It would be a good idea if they came in to see what is happening.” Another relative told us, “The regular staff know [relative] well. They will have a chat with [relative] and take an interest. The problem is when they have agency staff, and they don’t know [relative] at all. It is unsettling for the residents.” Management told us the staffing levels were the same on the weekend and they have recruited additional permanent staff who are currently working through their induction.

Appropriate checks were in place before staff started work including providing full work histories, references and a Disclosure and Barring Service (DBS) check. DBS provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

The registered manager assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff had received training in infection and prevention control and the provider had policies in place for staff to follow, should there be any outbreaks of infectious diseases. The service had regular cleaning schedules in place and staff had personal protection equipment (PPE) available for their use.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Staff had systems in place to safely manage medicines including refreshing medicine training and competency checks. Audits were in place to check medicines were being managed safely and people received their medicines when they needed them.