CQC inspection – 2018

On 27th March 2018 we were inspected by the Care Quality Commission (CQC). Im very happy to say that we were Fully compliant in all areas.

The report is now published online (our website also has a link). Some of the points mentioned in the report are listed below:

– A social care professional told us, “Based on recent reviews of people’s placements, I can confirm that resident’s safety whilst living at Willett’s Lodge is one of the most important areas for the care team.”

– The registered manager completed risk assessments and a programme of regular health and safety checks to ensure quality was measured and maintained. We observed audit activity for areas including, medicines, and fire safety and infection control.

– The provider had arrangements in place for the safe ordering, administration, storage and disposal of medicines.

– People and their relatives felt staff were skilled to meet the needs of people living with dementia and provide effective care

– “The food is always lovely here.”

– People’s relatives told us and we saw that the staff were caring and respectful. One person told us, “They care about people, they care about us”. Care and support provided was personalised and met peoples’ diverse needs. People and their relatives were included in the assessment of their needs and development of care plans.

– Quality assurance audits completed by the registered manager and provider were embedded to ensure a good level of quality was maintained. The provider was committed to improving the service through satisfaction surveys and as an active partner in local forums. The provider consistently demonstrated that the service monitored and made improvements to the systems when required.

– One person told us, “I like it here, I am well looked after.”

– The registered provider had oversight of health and safety through audits and checks of fire safety, LOLER, COSHH, Legionella, gas safety, food hygiene compliance checks and emergency plans. Personal Emergency Evacuation Plans (PEEPs) were in place for people. PEEPs provide information to staff on what action should be taken with people should the service be required to be evacuated in the event of an emergency.

– The environment remained clean and free from malodours

– Staff gave medicines respectfully having gained consent. One person told us after receiving their medicines, “They care about people, they care about us”.

– There were sufficient numbers of suitably experienced staff on duty to keep people safe and ensure their needs were met. Throughout the inspection, people’s emotional and physical needs were met. Requests for support made verbally or through the use of call bells were responded to promptly. Staff told us they had sufficient time to meet people’s needs and spend time with them to talk about their day or interests. One staff member told us, “It’s important to sit, talk and reassure people, the more time you spend with them, the more you understand their needs.”

– The registered manager had completed a national qualification in ‘dementia mapping’ training and was using the tool to work with staff to enhance their person centred care.

– The provider told us that the registered manager had worked closely with the Dementia ‘Living Well’ Team and people when designing the recent décor. They had used décor reminiscent of the style of décor people may have had in their own homes, with defined changes in colours and themes for different areas. The environment was spacious which allowed people to move around freely without risk of harm.

– The provider had carried out a ‘tasting session’ in October 2017 with the people and their relatives to design a new menu.

– “The care is excellent and I’m really happy with it,

– The registered manager was an active member of the team and demonstrated a very developed understanding of the needs of people living with dementia.

– Staff remained genuine in their concern for people’s wellbeing and independence. For example, one person was more relaxed when holding a doll, and staff ensured they had the doll at all times.

– The registered manager designed a care plan that gave staff clear guidance on the communication that the person used and how to respond to them.

– People’s backgrounds and life histories were evident within their personal spaces and within the communal areas. For example, one person had a replica house that they had hand built in their room. In the communal sitting area there were pictures that celebrated aspects of people’s lives.

– A social care professional told us, “My experience of the working with registered manager is positive and they always demonstrate initiative in identifying areas of learning. They are always prompt and responsive”.

– The provider was regularly available to support the registered manager and was present at the service twice a week.

– Staff told us they were well supported and there were clear lines of accountability and responsibility through their roles and embedded practices. This was demonstrated on the day of the inspection through observations of staff interacting with the registered manager and provider.

– The registered manager was continually looking to improve the culture of the service and was actively involved in local GPs meetings for care homes and was part of the local safeguarding adults board and engagement group.

– The provider continued to encourage an open and transparent culture. Staff and relatives were encouraged to provide feedback and to make suggestions for improvements in the service.

– A satisfaction survey was completed in 2017, which provided people and relatives with the opportunity to feedback about the quality of the service provision. The survey outcomes were consistently positive and the provider produced a letter for relatives detailing the improvements they had made in response to comments about the décor and cleanliness.

Srijit and I would like to thank the staff for their passion towards caring for the people at Willett Lodge. I would also like to thank all the relatives for their support and willingness to work with us.

I would also like to thank Social Services for supporting us and working with us.

Thank you

Asim & Srijit