Willett Lodge

Updated 8 September 2022

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 Health and Social Care Act 2008.

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 was undertaken by two inspectors 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

Willett Lodge is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Willett Lodge is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We used the information the provider sent us in the provider information return (PIR), and the monthly reports submitted in line with conditions of the providers registration. The PIR is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with four people who used the service and five relatives about their experience of the care provided. The Expert by Experience made calls to relatives remotely by phone. We observed people's care to help us understand the experience of people who could not speak with us. We spoke with 10 members of staff including the provider, the registered manager, care manager, registered nurses, carers, maintenance staff, the housekeeper and the cook.

We reviewed a range of records. This included nine people's care records and multiple medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the leadership team to validate evidence found. We looked at service user questionnaires, minutes from meetings, staff training and audit and quality assurance records. We requested feedback from five health and care professionals.

Updated 8 September 2022

About the service

Willett Lodge is a residential care home providing accommodation, nursing and personal care to up to 20 people in one adapted building. The service provides support to people living with a range of healthcare, mobility and sensory needs, including people living with dementia. There were 14 people living at the home at the time of our inspection.

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

Since our last inspection it was evident the registered manager and staff had made some improvements which had raised the standard of care people received and improved the governance of risks to people’s health and safety. Improvements were still required to ensure all systems were effective in providing managerial oversight and ensure the provider was always working in accordance with best practice guidance and legislation. Further improvements were required to keep people safe and ensure people consistently received dignified and person-centred care.

People at risk of choking were not always protected from avoidable harm because risks to their health and safety were not consistently managed. Processes did not ensure care plans and risk assessments contained detailed and person-centred information to accurately reflect the current needs of people and mitigate identified and potential risks. People were not always supported to receive their medicines as prescribed and there was a lack of effective systems to ensure medicines were always managed safely.

People had not always received a holistic assessment of their needs and preferences from which person-centred care plans could be developed. People’s dignity was not always respected by staff. Staff did not always have detailed guidance to respond to people and ensure they were supported in the most effective way. Not all people had care plans to guide staff and ensure people received information in a way they could understand. We have made a recommendation about improving the delivery of person-centred care.

People were observed in an environment which was not fully adapted for their needs. People were not always supported to take part in activities which would promote their social and emotional wellbeing. People were not always 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.

People and their relatives told us they felt safe. A relative told us, “I’m completely happy with everything at the home because I know one hundred percent that keeping everyone safe is one of the biggest things the care home offers.” People were cared for by staff who knew them well. We observed interactions between people and staff that were warm and genuine.

Accidents, incidents and safeguarding concerns were reported and investigated as required and actions taken to prevent reoccurrence. People were protected from the risk of abuse and staff were aware of their safeguarding duties and how to report concerns.

People and their relatives told there were enough staff with the appropriate skills and training to meet their needs. Staff were recruited safely and received supervision where opportunities to develop and feedback about their practice were discussed.

People, relatives and health professionals were complimentary about the service and the registered manager. Comments included, “Myself and my [person] cannot fault Willett Lodge and staff in anyway”, and, “It's a good home, and the staff do a fantastic job.”

The registered manager worked to achieve a positive culture and was committed to continuous learning and improving care. People had access to a range of health professionals and were cared for by staff who felt supported by the provider and registered manager. People, their relatives and staff provided feedback about the service which was listened to and acted upon to make improvements.

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 Requires Improvement (published 16 August 2021) and there were breaches of regulation. The provider was served a notice to impose conditions on their registration. The provider was required to submit monthly reports to CQC to demonstrate what actions they were taking to improve, by when, and how this would be monitored.

At this inspection some improvements had been made and the provider was no longer in breach of regulation 19 (Fit and proper persons employed). We found the provider remained in breach of regulation 12 (Safe care and treatment) and regulation 17 (Good governance).

Why we inspected

We undertook this unannounced, comprehensive inspection on 28 June 2022 to check the provider had complied with the conditions imposed on their registration. We needed to ensure that actions submitted in their monthly reports were embedded and confirm they now met legal requirements. We had also received concerns about moving and handling practices and the culture of the service. A decision was made for us to inspect and examine those risks.

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.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

After the inspection we contacted the provider about some of the concerns found during inspection. The provider sent us assurances and evidence that informed us of the immediate actions they had taken to address these concerns.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Willett Lodge on our website at www.cqc.org.uk.

Enforcement and Recommendations

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 monitor the service and will take further action if needed.

We have identified continued breaches relating to the safe care and treatment of people and the overall governance of the service. 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 and action plan and meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. 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.