Background to this inspection
Updated
3 December 2015
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
This inspection took place with one inspector on 15 October 2015 and was announced. The provider was given 24 hours’ notice because the location provides a domiciliary care service and we needed to be sure that someone would be in.
Before the inspection we asked the provider to complete and return a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and any improvements they plan to make. The provider completed and returned the PIR form to us and we used this information as part of our inspection planning.
We looked at other information that we held about the service including notifications, which are events that happen in the service that the provider is required to inform us about by law.
We spoke with four people and looked at their care plans and care records. We spoke with three members of staff, the care manager and registered manager.
As part of this inspection we looked at accident and incident reports, medicine administration records, quality monitoring and audit information, and the providers’ policies and procedures.
Updated
3 December 2015
This announced inspection took place on the 15 October 2015. This was the first inspection of the service since Axiom Care Limited had been registered as the provider IN May 2014
Willowbank is registered to provide personal care to people who live in Willowbank extra care scheme. At the time of our inspection 20 people were receiving a personal care service.
The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the scheme. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the scheme is run.
The providers’ policy on the safe administration and management of medicines had not been followed by staff. This meant that people were at risk of not receiving their prescribed medicines. Audits that had identified issues in medicine management had not been reviewed to check that the required action had been taken.
People’s needs were assessed and the information in the care plans was detailed. This meant staff could support people and meet their needs in line with their preferences.
Risks to people’s safety had not always been reassessed. Some risk assessments were inaccurate but staff were aware of the actions they should take to support people safely.
The risk of harm for people was reduced because staff knew how to recognise and report abuse.
The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) Deprivation of Liberty Safeguards (DoLS) and to report on what we find. We found that people who used the service had their capacity to make day-to-day decisions formally assessed.
The recruitment process ensured that only suitable staff were employed to provide care to people using the service. There were sufficient staff to meet the needs of people receiving care and support in a timely way.
People’s health and welfare was monitored by staff to ensure health professional input was given when necessary.
People’s privacy and dignity was respected by all staff. People were aware that there was a complaints procedure in place.
Staff felt supported by the managers because there were opportunities for open discussion. Staff felt they were able to raise any concerns through staff meetings and the open culture of the service.
We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.