Willett Lodge

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.

This service scored 75 (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. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. The registered manager and their team undertook investigations when things went wrong, and put measures in place to minimise reoccurrence. For example, staff attended coaching sessions and procedures were reviewed in response to a medicine error. A manager from the provider’s head office told us, “I’ve introduced incident analysis when anything happens, to identify what can be done differently, lessons are learned from root cause analysis. Daily huddles have been introduced, identifying risks and anything extra we may need to know. It’s all about communication.”

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. Pre-admission assessments were undertaken prior to people moving into the service and included information from people, their relatives and healthcare professionals. A relative told us, “They did an assessment, everything was done. Not having any experience of placing a loved one in a care home it was a case of feeling your way. [Registered manager] has the right personality for the job. They are brilliant, they work from the ground upwards.”

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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. People told us they felt safe, a person said, “Yes I do feel safe, because I am happy the staff can cope with me and the other who live here.” Staff received training and followed the provider’s policy to ensure people were safeguarded from the risk of harm or abuse. Staff worked within the principles of the Mental Capacity Act 2005 (MCA). Where people had a Deprivation of Liberty Safeguards (DoLS) authorisation in place, conditions to their authorisations were being met. For example, a person required a mental capacity assessment for a sensor mat; this had been completed. The registered manager held a DoLS tracker to ensure authorisations remained current, were in date, and conditions were met.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. People were supported to take risks in line with their wishes, a person told us, “I like a smoke, when I first came I used to have to go with someone when I wanted to smoke as I used to fall all the time, so they came with me. I am steady now so I go out on my own.” Staff were aware of people’s risk assessments and told us how they mitigated risks. For example, to encourage flame retardant aprons whilst smoking and to review topical creams which may contain paraffin. Risks in relation to people who may display emotions of distress were well managed. Care records guided staff on how to prevent people’s distress and how to support them should they become upset. We observed staff supporting people in accordance with their care plans.

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 registered manager undertook daily walk rounds of the service and additional checks were made by managers of the provider’s head office. An ongoing programme of maintenance was planned to address areas identified for refurbishment. During our assessment a toilet was being refitted and the shower rooms had recently been upgraded. The registered manager identified the bath was not accessible for people and had arranged for it to be moved so people could safely access it with a hoist.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. Staff were recruited safely, additional checks such as, the right to work in the UK and verification of registered nurse’s PIN numbers (personal registration numbers assigned by the Nursing and Midwifery Council) were conducted and continually reviewed. Staff told us about the training offered and said, “We have gone to a lot of training, I think it’s enough to help me support the residents.” Staff received blended learning of online training and practical training. Additional courses were sought in response to people’s needs, for example, advanced training in fluid thickening for people with swallowing difficulties.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Housekeeping staff worked hard to ensure the service was clean, audits were completed to ensure staff followed the infection prevention and control policies. Staff used and disposed of personal protective equipment (PPE) appropriately. A relative told us, “It’s as clean as it can be, it doesn’t smell. You don’t notice smells anywhere.”

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people and, where appropriate, people’s relatives in planning, including when changes happened. Staff had completed medicine training and their competencies were regularly assessed. Some people required their medicines to be administered covertly (without their knowledge but within their best interests). Management followed legal guidelines for covert medicine administration. People’s medicines were reviewed frequently and staff contacted prescribers if medicines were ineffective. A relative told us, “They recently reviewed everything as [person] wasn’t taking their medication very well, they (staff) asked the nurse practitioner to review.”