Dover House

Updated 22 February 2023

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 carried out by 3 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

Willow Park 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. Willow Park 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 provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

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 received about the service since the last inspection. This included details about incidents the provider must notify us about, such as serious injuries. We sought feedback from the local authority and other professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 13 people who used the service and 12 relatives about their experience of the care provided. We observed multiple interactions between people and staff throughout the day. We spoke with 13 members of staff including the registered manager, compliance manager, nurses, care workers and support staff. We also spoke to visiting professionals. We looked at records relating to people’s care and support including risk assessments, care plans and medicine administration records. We looked at 4 staff recruitment files. A variety of records relating to the management of the service were reviewed including health and safety checks, meeting notes, training records and audits.

Updated 22 February 2023

About the service

Willow Park Lodge is a care home providing accommodation with nursing and personal care for up to 79 people. The service provides care and support for people with a range of needs, including people living with dementia. The service also provides short term care for people who need assessments of on-going care needs. Willow Park Lodge is arranged across 4 levels, the top floor is currently not being used. The ground floor mainly accommodates people requiring residential care, the first floor provides care for people living with dementia and the second floor is used for short term assessments. At the time of our inspection there were 52 people using the service.

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

There was a registered manager in place, supported by a team of other managers but the structure was not always clear for people and visitors. There were quality monitoring processes in place but actions to address shortfalls were not always clearly documented.

Some care plans did not always contain enough detail to provide staff with the guidance needed to provide consistent care; and recording of information, such as hourly checks or fluid intake, was inconsistent. Not all risk assessments had been updated when a person’s circumstances changed.

People, relatives and staff told us the registered manager was approachable, accessible and supportive, and they were confident to raise concerns if necessary.

People and their relatives told us they felt safe and happy living in the service. One relative said, “Yes they are safe, they are content and relaxed.” Another relative said, “Yes, [relative] is safe. They had a few falls but walking much better now.”

Risk to people had been assessed using recognised tools and documented, for example, risks of falls or skin damage. Information was available for staff to manage these risks, and staff knew people well. Environmental risks, for example, fire safety and water temperatures were managed. A relative told us, “Staff went out of their way to improve [relative’s] situation.”

There were enough staff deployed to provide safe care and staff had been trained to do their role. Medicines were managed safely and there were measures in place to prevent the spread of infection. The service was clean and uncluttered. People said it was a very clean and well-maintained home. A relative said, “It’s been taken over and refurbished, it’s like a hotel; clean and functional.”

Most people enjoyed the food and their dietary needs and preferences were met, for example meat-free meals. People told us they had choices, but if they wanted something different, they only had to ask. One relative said, “I can’t fault the food, it’s all very good. The chef will always make something else if needed.”

People were involved in decisions about their care and they received care which promoted their dignity and encouraged independence. Relatives told us they were involved in their relative’s care plans where appropriate and were always kept up to date with any changes. The service sought feedback from people and relatives through meetings and surveys.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The service was registered with us on 5 July 2022 and this was the first inspection. The last rating for the service under the previous provider was requires improvement, published on 24 November 2021.

Why we inspected

The inspection was prompted in part due to concerns received about people’s safety, standards of person-centred care, cleanliness and medicines management. A decision was made for us to inspect and examine those risks. We found evidence that the provider needs to make improvements. Please see the safe and well led section of this full report.

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.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.