2 May 2018
During a routine inspection
At our last inspection on 16 September 2015 we rated the service Good. At this inspection we found the evidence continued to support the overall rating of Good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.
A registered manager was in post at the time of our inspection. The registered manager of the Willow Centre is also the Chief Executive of the Trust. A registered manager is a person who has registered with the Care Quality Commission 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. Day to day responsibility for the service was delegated to the Scheme Leader who oversees the day to day running of the centre. The Scheme leader is supported by a deputy manager.
Risk assessments were detailed and contained sufficient information to guide staff on how to mitigate risks. Procedures were in place to analyse accidents and incidents, such as medication errors and falls, with a focus on reflection for future learning and prevention.
People were supported to live in a clean and well-maintained environment. A range of health and safety checks were completed to ensure the equipment and premises were safe for people to live.
Staff had received training in the safe administration of medicines and medication was stored securely.
Safe recruitment procedures were in place to ensure that staff were suitable to work with vulnerable people. There were appropriate numbers of staff deployed to meet people’s needs and to ensure people received support when they needed it. Staff had received training in safeguarding and knew how to recognise and report abuse to local partner agencies.
Staff received an induction and suitable training to complete their job role effectively. All staff were regularly supervised in their role and received an annual appraisal. Staff spoken with told us that they were supported with their learning and development and felt they could raise any issues both formally and informally.
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 at the service supported this practice. The service was working in accordance with the Mental Capacity Act and DoLS (Deprivation of Liberty Safeguards) and associated principles. Mental capacity assessments were completed and best interest decisions were made on behalf of those who lacked capacity.
People’s overall health and well-being needs were being safely and effectively supported. Staff maintained effective communication within the team and with outside partner agencies to ensure people’s outcomes were met. People were offered a varied diet and the chef catered to people’s individual dietary preferences.
The two people who used the respite service were unavailable on the day of our inspection and therefore we were unable to speak to them directly however the three relatives we spoke to all described staff as 'kind' and 'caring'. One relative described the service as a ‘godsend’ and another said 'superb’. People’s relatives also spoke positively about the environment and facilities at the Willow centre. One relative commented, “Willow Centre is a nice place, because they don’t have that many people, it’s a home from home environment.”
Care plans contained information about people’s likes, dislikes, preferences and routines. It was evident throughout the course of the inspection that staff were familiar with the individual needs of the people they supported.
People using the respite service had access to a wide range of activities which were provided through the day centre based on site. The activities co-ordinator employed by the registered provider maintained links with local community groups to promote social stimulation.
A formal complaints process was visible around the home but we were informed by relatives that any complaints or concerns could be discussed openly with the scheme leader or deputy manager as and when they needed to be.
Quality assurance procedures had been developed to meet the needs of the service. This included audits in respect of care plans, health and safety, human resources and accident and incidents to monitor and improve standards at the home. Opportunities were provided for people and their relatives to comment on their experiences and the quality of service provided through the use of annual surveys.
Staff told us they felt well supported and described the management team as being ‘supportive’ and ‘approachable’. Staff meetings were held regularly and staff surveys were circulated annually.
The registered manager had notified the Care Quality Commission (CQC) of events and incidents that occurred at the home in accordance with our statutory requirements.
The ratings awarded at the last inspection were displayed in the communal area of the home and on the registered provider’s website.