Willowthorpe Care Home

Updated 9 January 2019

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 unannounced inspection took place on the 28 and 29 November 2018. The inspection was carried out by two 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.

Before the inspection, the provider completed a Provider Information Return (PIR). This is a form that requires them to give some key information about the service, what the service does well and improvements they plan to make. We also reviewed, information we held about the service including statutory notifications. Statutory notifications include information about important events which the provider is required to send us.

During the inspection we spoke with 11 people, five relatives, seven staff, the assistant manager and the registered manager.

We looked at two care plans, three staff employment files, quality monitoring records’ and other relevant documents relating to how the service operated.

Updated 9 January 2019

Willowthorpe is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The inspection took place on 28 and 29 November 2018 and was unannounced. At our last inspection on 16 August 2017, the service was found not to be meeting all the required standards we looked at.

At this inspection we found that the provider had made the improvements required.

There was a manager in post who had registered with the Care Quality Commission (CQC). 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 and associated Regulations about how the service is run.

The service was safe. Recruitment practices ensured that suitable staff were employed. Staff received training in safeguarding and understood how to report concerns. Staffing levels were reviewed regularly to ensure people’s needs were met. Accidents and incidents were monitored to identify any trends or patterns to ensure appropriate actions could be taken. Medicines were managed safely by staff that received appropriate training. People were protected from the risk of infections by staff who followed correct infection control procedures.

The service was effective. Staff worked in line with the principles of the Mental Capacity Act. People’s nutritional needs were managed appropriately. Staff received appropriate training to meet people’s needs effectively. Staff received inductions and supervisions and felt supported to do their job. However, supervisions were still not where the registered manager wanted them and required improving. People could access other health services when needed.

The service was caring. Staff respected people’s privacy and dignity and supported people to maintain relationships. Staff knew people well and cared for them in a compassionate way. Support delivered by staff was supportive, kind and caring. People were involved in deciding how their care was provided and staff promoted their choice.

The service was responsive. People`s needs were assessed to ensure they received person-centred care and the support they required. People were involved with their care plan reviews. People were given the opportunity to think about what was important to them regarding end of life care. People knew how to raise concerns if required.

The service was not consistently well-led. Care records still needed further improvements. One person’s requirements when being supported with a hoist were contradictive and the audit trail to show why the changes were in place had not been documented appropriately. The registered manager was clear about their vision regarding the purpose of the home. Staff understood their roles and responsibilities and worked well as a team. Staff felt they could approach the management team at any time. There were effective systems to monitor the quality of the service, identified issues were actioned and lessons learned. People, relatives and staff were positive about how the home was run.

Further information is in the detailed findings below.