Willis Lodge Care Home

Updated 13 July 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.

Inspection team

The inspection was carried out by two inspectors and an Expert by Experience (EXE) . An EXE is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Willis Lodge Care Home 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. Willis Lodge Care Home is a care home without 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 used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.

We asked local authority commissioners, and other agencies such as Healthwatch for their views of the service. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.

We used this information and our internal records to plan our inspection.

During the inspection

We spoke with five people. We asked them about their experiences of the care provided. We spoke with 8 members of staff. This included, 2 support workers, support manager, administrator, kitchen manager, maintenance person, deputy manager and registered manager.

We reviewed a range of records. This included all or part of the care records for 9 people as well as medication administration records and the daily notes recorded by care staff. We looked at staff files in relation to recruitment, supervision, and training. We also viewed a variety of records relating to the management of the service, including policies and procedures and training records.

Updated 13 July 2023

About the service

Willis Lodge Care Home is a residential care home, providing personal care to 33 adults of all ages at the time of the inspection. The service can support up to 37 people. The service provides support primarily to people with mental health needs.

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

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.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence, and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

Changes to people’s care records had not always been completed in a timely manner following increased risk to their health and safety. Action to address concerns regarding legionella had not been fully completed. Governance procedures had not highlighted these issues; however, we have been informed that action has now been taken. The impact of these was minimal on people.

People felt safe at this home. They received their medicines when needed and there were enough staff in place to provide safe care. The home was clean and tidy, and incidents were reviewed, and action taken to reduce recurrence.

People’s needs were assessed prior to them living at the home, ensuring their care and support needs could be met. Staff were well trained, skilled, and experienced. People received support with the meals, including preparing meals for themselves where able. People had regular access to health and social care professionals. The home environment was suitable to people’s needs.

Staff were kind, caring and provided respectful care. People’s privacy was respected. People felt involved with decisions about their care needs. People received person-centred care. They were encouraged to socialise with others and to lead active lives. There was an aim to support people with living more independently. Complaints were managed appropriately. Staff communicated with people in a way that did not discriminate. End of life care not currently provided.

People and staff liked the registered manager and found them to be approachable and well-meaning. There was a positive atmosphere and culture at the home. Improvements had been made since our last inspection to the process of reporting incidents to the CQC.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 18 November 2019) and there was a breach of regulation. The provider completed an action plan after the last inspection to how what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

At our last inspection we recommended that improvements were made in relation to safeguarding procedures and medicines. At this inspection we found the provider had acted on these recommendations and improvements had been made.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

Follow up

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