This inspection took place on 31 October 2014 and 03 November 2014 and was unannounced. This meant the staff and provider did not know we would be visiting.
Willowdene Care Home provides care and accommodation for up to 48 people and includes a small, separate 12 bed unit for older people living with dementia. It also provides nursing care. On the day of our inspection there were 43 people using the service.
The home had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (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.
Willowdene Care Home was last inspected by CQC on 29 May 2013 and was meeting all the regulations inspected.
During our inspection visit we found there were insufficient numbers of staff on duty in order to meet the needs of people using the service. There was only one member of staff in the residential part of the home for the 12 residents, one of whom had nursing needs and required 2:1 care.
The provider had an effective recruitment and selection procedure in place and carried out relevant checks when they employed staff.
We saw evidence that thorough investigations had been carried out in response to safeguarding incidents or allegations and comprehensive medication audits were carried out regularly by the manager.
Training records were up to date and staff received regular supervisions and appraisals, which meant that staff were properly supported to provide care to people who used the service.
People had access to food and drink throughout the day and we saw staff supporting people in the dining room at lunch time when required.
We saw in the care records consent was obtained for photographs and the sharing of information, as well as end of life wishes. However, not all of these records were signed by the person using the service or a family member. This meant we could not be sure if the information contained in the record was a true reflection of people’s wishes.
The layout of the building provided adequate space for people with walking aids or wheelchairs to mobilise safely around the home, and the Maple Suite was suitably designed for people with dementia.
CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The Deprivation of Liberty Safeguards (DoLS) are part of the Mental Capacity Act 2005. They aim to make sure that people in care homes, hospitals and supported living are looked after in a way that does not inappropriately restrict their freedom. We discussed DoLS with the registered manager and looked at records. We found the provider was following the requirements in the DoLS.
People who used the service, and family members, were complimentary about the standard of care at Willowdene Care Home. They told us, “The care here is brilliant”, “she loves it here, it’s the healthiest she’s been for years”, “everything about the care home, I can’t fault” and “happy with the care”.
We saw staff supporting and helping to maintain people’s independence. We saw staff treated people with dignity and respect and people were encouraged to care for themselves where possible.
On the first day of our inspection visit we saw that people’s care records were left outside each room, tucked behind the hand rails. As care records contain personal information, we discussed this with the registered manager who told us that it was not normal practice and should not be happening. The registered manager rectified it straight away and care records were placed back in people’s rooms. On the second day of our inspection visit, we did not see any care records in the corridors.
We saw that the home had a full programme of activities in place for people who used the service.
All the care records we looked at showed people’s needs were assessed before they moved into Willowdene Care Home and we saw care plans were written in a person centred way.
Some care plans we looked at did not contain sufficient detail about people’s needs and preferences and some risk assessments were missing important information. We also saw that risk assessments were not always up to date and some care plan reviews were overdue. This meant that care records were inconsistent.
We saw a copy of the provider’s compliments, concerns and complaints procedure, and saw that complaints were fully investigated.
The provider had a robust quality assurance system in place and gathered information about the quality of their service from a variety of sources.
You can see what action we told the provider to take at the back of the full version of the report.