Archived: The Willows Specialist Dementia Unit and Intermediate Care Service

Updated 27 April 2018

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.

The inspection took place on 5 and 6 March 2018 and was unannounced. The service was inspected by one inspector 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, e.g. dementia care.

We did not have any information to use from the Provider Information Return as it was not requested due to technical issues. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. Prior to the inspection we looked at all the information we had collected about the service. This included previous inspection reports, information received and notifications the registered manager had sent us. A notification is information about important events which the service is required to tell us about by law. However, the registered person did not always send all notifications as required.

During the inspection we spoke with four people who use the service. We spoke with the deputy manager. We observed interactions between people who use the service and staff during our inspection. We received feedback from the staff, as well. We contacted five community professionals for feedback. We receive feedback from two professionals. We looked at five people's care plans, monitoring records and medicine sheets, staff training records and the staff supervision log. We looked at records relating to the management of the service including two recruitment records, the compliments/complaints log and accident/incident records. We checked medicines administration, storage and handling. We reviewed a number of other documents relating to the management of the service. For example, the electrical equipment safety check certificates, gas safety certificate, fire risk assessment, fire safety checks, legionella risk assessment and quality assurance records.

Updated 27 April 2018

The inspection took place on 5 and 6 March 2018 and it was unannounced. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

The Willows Specialist Dementia Unit and Intermediate Care Service is purpose built and split into two adjoining units. The dementia unit provides a service for up to 16 people. The intermediate care unit comprises of 10 small flats, which can provide up to six week's rehabilitation following an injury or illness. At the time of our inspection, six people were living in the dementia unit and 10 people were living in the flats. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

The service had a registered manager as required. However, they were on extended leave at the time of the inspection. A registered manager is a person who has registered with the CQC to manage the service. 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 service is run. The deputy manager was overseeing the service in the absence of the registered manager. They assisted us with the inspection on both days.

During this inspection we found breaches of two regulations, Regulation 14 and Regulation 18 of Care Quality Commission (Registration) Regulations 2009. The registered person had not submitted notifications as required in good time informing CQC about the outcome of six applications of Deprivation of Liberty Safeguards. The registered person also had not submitted a notification informing CQC about the absence of the registered manager for longer than 28 days. We informed the management about this on our first day of inspection. However, there was a delay in submitting all notifications required including a notification of the return of the registered manager. You can see what action we have asked the provider to take at the end of the full version of this report. When there is a breach or more, the overall rating cannot be Good.

People told us they felt safe living at the service. Staff understood their responsibilities to raise concerns and report incidents or allegations of abuse. They felt confident issues would be addressed appropriately.

Staff training records indicated which training was considered mandatory. Most of the staff were up to date with their mandatory training but some were due their refresher training. The deputy manager was overseeing and booking training when necessary to ensure all staff had the appropriate knowledge to support people. We have made a recommendation for the management to refer to the current best practice guidance on ongoing training and monitoring for social care staff.

Staff had ongoing support via regular supervisions with their senior staff. They felt supported by the registered manager and senior staff and maintained great team work. Staff had handovers and meetings to discuss any matters with the team. There were appropriate recruitment processes in place. All necessary safety checks were completed to ensure prospective staff members were suitable before they were appointed to post.

The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 Deprivation of Liberty Safeguards and to report on what we find. The deputy manager had acted on the requirements of the safeguards to ensure people’s rights and freedom were protected. They made appropriate applications to ensure people's liberty was not restricted in an unlawful way.

People told us staff were available when they needed them and staff knew how they liked things done. The deputy manager reviewed staffing numbers to ensure enough qualified and knowledgeable staff were available to meet people's needs at all times. Staff were knowledgeable and focused on following the best practice to make sure people were supported appropriately. We observed people were treated with care and kindness. People and their families were involved in the planning of their care.

The management carried out risk assessments and had drawn up care plans to ensure people's safety and wellbeing. Staff recognised and responded to changes in risks to people who use the service. These changes were reported to the senior person to ensure a timely response and appropriate action was taken.

There were contingency plans in place to respond to emergencies. The premises and equipment were cleaned and well maintained. The dedicated staff team followed procedures and practice to control the spread of infection and keep the service clean. The staff ensured maintenance checks were up to date. The premises and adaptations were dementia friendly.

People had sufficient to eat and drink to meet their nutrition and hydration needs. Hot and cold drinks and snacks were available between meals. People were supported to have their meals where necessary. People had their healthcare needs identified and were able to access healthcare professionals such as their GP. Staff knew how to access specialist professional help when needed. The service worked well with other health and social care professionals to provide effective care for people.

People received their prescribed medicine safely and on time. Storage and handling of medicine was managed appropriately. We found one minor error, which was rectified, and records were accurate.

We saw care was provided with kindness and compassion at all times. People told us they were happy with their care and support. The management was working with the staff team to ensure caring and kind support was provided in a consistent way. People confirmed staff respected their privacy and dignity. People were able to engage in activities, spend time with their visitors or if they chose be by themselves. Their choices were always respected. We observed people were offered some activities and were encouraged to join in.

Staff felt the management was approachable and supportive, and they communicated well to ensure smooth running of the service. People felt the service was managed well and that they could approach management and staff with any concerns.

The management team had reviewed, assessed and monitored the quality of care with the help of staff and other members of the organisation. They encouraged feedback from people and families, which they used to make improvements to the service. The service ensured people were protected against the risks of receiving unsafe and inappropriate care and treatment.

Further information is in the detailed findings below.