The Care Quality Commission (CQC), has downgraded the rating at Hampshire care home Willow Brook, to inadequate and placed it into special measures to protect people, following an inspection in November.
Willow Brook, run by Assure HealthCare Group (South) Limited, is a residential home in Fareham, Hampshire which provides personal care for up to five people with learning disabilities, mental health, and complex needs.
The inspection was prompted in part due to concerns CQC received regarding a person using the service who sustained a serious injury. This matter is subject to further investigation by CQC. The information shared with CQC indicated potential concerns around the timeliness of seeking medical intervention. This inspection examined those risks.
CQC undertook a focused inspection to rate the areas of safe and well-led, however; during the inspection this was expanded to include rating how effective they were.
Following the inspection, the overall rating for the home has dropped from good to inadequate, as have the areas of safe, and well-led. Effective has been re-rated as requires improvement. How caring and responsive the service was, were not included in this inspection and remains rated as good from the previous inspection.
CQC has taken further enforcement action, which will be reported on when we are legally able to do so. Willow Brook has also been placed into special measures. This means CQC is closely monitoring it to ensure people are being kept safe, and it will be inspected again to assess whether improvements have been made.
Roger James, CQC deputy director of operations in the south, said:
"When we inspected Willow Brook, we were disappointed to find poor leadership and a lack of effective systems and processes was preventing staff from delivering safe, person-centred care.
“Leaders need to do more, to create a culture and environment where people aren’t being made vulnerable. Leaders were overlooking potential signs of abuse and weren’t always passing on information of concern to other agencies when needed. For example, leaders hadn’t always considered that unexplained bruising might indicate abuse and need further investigation. Our inspectors found two incidents that should have been referred to safeguarding teams but hadn’t been, putting people at risk of harm.
“We saw that people’s needs weren’t always being assessed, and their care plans weren’t always reviewed after incidents occurred. For example, staff didn’t have guidance to support someone using the service who had depression and a medical condition affecting their heart. This meant if their conditions got worse, there could be a delay with seeking medical attention.
“During the inspection we saw one person who had difficulty swallowing and was at risk of choking. This person wasn’t being supported to eat safely. This demonstrates that staff weren’t receiving all the training they needed to support people.
“The home was untidy and unclean in many areas. Inspectors found rooms with unpleasant odours, dirty floors and work surfaces, and one person’s bathroom had mould growing on the wall.
“We’ll continue to monitor the service closely including through future inspections. If we are not assured improvements have been made, we will not hesitate to take further enforcement action to protect the people at Willow Brook.”
Inspectors also found:
- People weren’t always being supported in the least restrictive ways possible. For example, some people were checked throughout the day and night. Their care assessments didn’t show how it had been decided this level of supervision was in their best interest and whether other arrangements had been considered
- Staff displayed a lack of understanding of the Mental Capacity Act and how this impacted on people using the service
- Medicines weren’t always being managed and administered safely. Staff did not always have guidance on how to give people ‘as required’ medicines which they’d been prescribed
- In addition to concerns about the cleanliness of the home, infection risks were poorly managed. Inspectors found refuse bins were being used without lids or bin bags and some bins were visibly dirty
- People’s food wasn’t being managed safely and this put them at risk of falling ill. Inspectors found expired food in the cupboards and opened food wasn’t being discarded when it should be. Food was also stored unsafely, for example a packet of dips was being stored between two packets of raw meat
- Fire risks weren’t always managed safely. In a recent fire evacuation drill, leaders had found staff needed additional training to support safe emergency evacuation, but at the time of inspection this training hadn’t taken place
- People, their relatives and staff were not always engaged and involved in planning people’s care.
However,
- The home had enough staff to meet people’s needs and relatives gave positive feedback on staff
- People were treated by staff in a kind and caring manner
- There were weekly calls in place with the local GP to discuss people’s medical needs. Inspectors saw the documentation confirming these calls took place
- Staff were found to be recruited safely with the appropriate pre-employment checks completed.