On 8th October 2012 we had an unannounced CQC inspection at Willett Lodge. We have now received the Final Report and i am very happy to say that we are FULLY COMPLIANT.
Some of the points noted on the report were;
1 – One person we spoke said “they take good care of me, no doubt about it.” Relatives and visitors we spoke to said the level of care was good, and a relative said to us that staff were “very caring and committed to all the residents.”
2 -We observed that safe care was provided to people, and that activities people wanted to participate in took place.
3 – One person told us that staff were “very caring and committed to all the residents.”
4 – During this inspection we case tracked four care plans in detail. In all care plans seen, peoples needs had been assessed and care and treatment was planned and delivered in line with their individual care plans. The four care plans all provided information on how the person’s mobility and skin integrity needs were addressed. One care plan seen included information to inform staff about ways in which they could engage with the person to distract them from repetitive behaviours.
5 – Care plans had been completed for all care needs identified, and included risk assessments where this was appropriate. For example where the person’s weight needed to be closely monitored. All care plans and risk assessments seen had been reviewed regularly. There was evidence that where risks to a person’s weight and nutrition was recorded that appropriate referrals had been made to the GP or other medical staff. Appropriate action such as nutritional support had then been put in place.
6- There was enough equipment to promote the independence and comfort of people who use the service.
7- People were protected from unsafe or unsuitable equipment because the provider had ensured that required equipment inspections had been completed. Records showed that the hoists had been inspected regularly within the recommended intervals.
8- In care plans we saw risk assessments which identified the method of lifting or hoisting required for the person. The manager said that reviews of the risk assessment would consider if the equipment needs of the person had changed, and this was seen in the risk assessments we looked at.
9- The provider had an effective system to regularly assess and monitor the quality of service that people receive. The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others.
10- During our inspection we saw that a number of audits had been completed. These included monitoring of medication, the condition of the premises, health and safety, fire safety, and infection control. The infection control audit dated August 2012, for example, noted that all staff had followed the home’s guidelines on use of protective equipment, washing hands, and food preparation.
The record of a check in August 2012 on privacy and dignity told us that staff respected people’s privacy and dignity.
11- We saw records of monitoring visits carried out monthly by the provider. These visits included a check on a sample of care plans, medication arrangements and the environment. The provider had recorded discussions held at these visits with staff, people living in the home, and their relatives and visitors.
12- The provider had attended meetings once a week with the home’s clinical lead nurse to monitor the risks to each person and evaluate the action being taken. The record we saw for the previous meeting showed there had been discussion about care needs and risks for each person and the actions agreed to maintain their safety.