Willow House

We found the following examples of good practice.

Safe arrangements were in place for peoples’ relatives and professionals visiting the service. This included reviewing evidence of a confirmed negative lateral flow device test (LFD), a recent negative polymerase chain reaction (PCR) test result. Vaccination against COVID-19 and the requirement to show a COVID-19 pass. Visitors were encouraged to wear personal protective equipment (PPE) in line with government guidance.

The provider introduced a designated, temporary staff changing area that was separate from the main building to reduce the risk of cross infection.

The provider ensured instructions on correct hand hygiene technique were displayed in bathrooms including in the reception area and used by visitors and staff.

There was a purpose-built visitor pod used for visits if people or their relatives preferred visits away from the main building.

Policies, procedures and risk assessments relating to COVID-19 were up to date which enabled staff to keep people safe. This included the policy that ensured safe admissions, in line with the government guidance.

All staff had received training and followed correct processes for using PPE and maintaining infection control standards. The provider ensured a sufficient stock of appropriate PPE and signage to remind staff and visitors about the correct guidance for donning, doffing and disposing of PPE.

The registered manager reported good support from the local health professionals and the provider.

The service was clean and fresh. In addition to the regular cleaning regime, staff carried out regular cleaning of any frequently touch point surfaces. Regular audits took place and actions had been followed up when required.

People’s experience of using this service: People told us they were happy living at Willow House, they felt safe and well cared for. Staff were seen to be kind, caring and knew people and their relatives well.

Relatives and staff told us the home had improved since the last inspection, which they attributed to the new management team and spoke positively about the changes that had taken place.

We found improvements had been made with regards to the safety, effectiveness and management of the home. However, time was needed time to fully embed those changes and show sustained improvement.

The registered manager was aware of their responsibilities under the duty of candour, that is, their duty to be honest and open about any accident or incident that had caused, or placed a person at risk of harm. However, we noted the home had been slow to tell us (CQC) about specific events which they were legally required to do.

People received their prescribed medicines on time and in a safe way. However, where people had been prescribed medicines they only needed to take occasionally guidance provided to staff was not always clear. We have made a recommendation in relation to medicines.

People were supported to have maximum choice and control of their lives; however, we have recommended the registered manager reviews all documentation in relation to the recording of best interests decisions.

People received a service that was safe. The registered manager and staff understood their role and responsibilities to keep people safe from harm, protect people from discrimination and ensure people's rights were protected.

Risks had been appropriately assessed and staff had been provided with information on how to support people safely.

People, along with family members were encouraged to share their views about the care people received through regular reviews and meetings.

There were sufficient numbers of staff employed to ensure people’s needs were met. Staff had time to sit and engage people in conversation and to support people’s involvement in social activities.

Recruitment practices were safe and staff were well-trained.

The home was clean, well maintained and people were protected from the risk and/or spread of infection as staff had access to personal protective equipment (PPE).

Rating at last inspection: The home was previously rated as ‘Required Improvement.’ The report was published on the 29 August 2018.

Why we inspected: This inspection was scheduled based on the previous rating.

Follow up: We will continue to monitor the home through the information we receive until we return to visit as per our re-inspection programme.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Willow House 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. Willow House is registered to provide personal care and support for up to 30 older people some of whom may be living with dementia or have a physical disability. The home does not provide nursing care; people living there would receive nursing care through the local community health teams. At the time of the inspection there were 17 people living at the home.

Willow House has been inspected five times since May 2015. At each of these inspections, we found breaches of regulation and the home was rated as ‘Requires Improvement’.

At this inspection, we found further improvements had been made, although some improvements were still needed. People told us they felt safe and happy living at the home, however we found that risks to people were not sufficiently well managed. Support was not always provided in a person centred way: governance systems have not been sufficiently robust over a period of the last three years to identify and bring about the required improvements.

The home did not have a registered manager. A new manager had been appointed; they had applied to be registered with the Care Quality Commission and were available throughout this inspection. They were referred to as the manager throughout this report. A registered manager is a person who has registered with the Care Quality Commission to manage the home. 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 home is run.

The home’s quality assurance and governance systems were not effective. Although some systems were working well and improvements had been made since the last inspection, other systems had not identified the concerns we found during this inspection.

Risks to people’s health and wellbeing were not always managed safely and the systems in place to minimise risks to people’s health and safety were not always understood by staff. Where risks had been identified, action had not always taken to minimise these risks. For example where guidance had been provided by external professionals, it was not always followed. This placed people at increased risk of choking, developing pressure ulcers and increased risk of falls.

Whilst some premises checks had been completed we noticed a number of bedrooms windows were not properly restricted. There was no evidence the provider had carried out any form of risk assessment in relation to needs of people currently living at the home and the risks posed by having unrestricted windows that were easily assessable. Following the inspection, the manager gave assurance that following a risk assessments all windows identified were now being appropriately restricted.

Some improvements were needed to the homes recruitment processes to ensure people were kept safe. We looked at the recruitment files for ten staff. We found some recruitment checks had been carried out, but others had not. For example, one person did not have a DBS certificate in place and had been working at the home since November 2017. This meant the provider could not be assured they had taken sufficient action to ensure staff were of good character. Following the inspection, the manager assured the commission that the persons DBS was now in place.

Some people’s care and support was not always appropriate, did not meet their needs, or did not reflect their preferences. Prior to the inspection, we received concerns that night staff were expected to get people up early in the morning. We visited the home at 6.45am on 8 January 2018 and found five people were up and dressed and in the process of having breakfast in the dining room. Three of the people we spoke to told us staff had woken them up Against their wishes; We asked staff why people were up so early. Staff told us they were normally expected to get five people up each day. We discussed what we found with the manager who told us people were free to choose when they wanted to get up and go to bed and assured us they would address what we found with the staff team.

Prior to this inspection, we received some concerns regarding staffing levels at the home. We discussed the current staffing levels with the manager who told us they felt there were enough staff on duty to meet people’s needs. However, they did not have a system for determining how many care staff were needed in relation to the number of people who lived in the home and their level of dependency.

We have made a recommendation that the provider uses a suitable tool to determine people’s level of dependency to ensure that staffing levels are sufficient to meet people’s assessed needs

We looked in detail at the care records for six people with a variety of care needs and found that one person’s individual needs had not been assessed or care planned to meet them or mitigate risks. Records showed this person had been admitted to the home seven days prior to our inspection for respite care. This person did not have a care plan and the home had not assessed any of the risks associated with providing care and support for this person during their stay.

People received their medicines when they needed them and in a safe way. People were cared for and supported by staff who knew them well. Staff were kind, caring and treated people with dignity and respect. The manager and staff understood their roles and responsibilities to keep people safe from harm; protect people from discrimination and ensure people's rights were protected.

People were encouraged to make choices and were involved in the care and support they received. Staff displayed a good understanding of the principles of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguarding (DoLS) in ensuring people’s rights to make choices where they had the capacity to do so were respected.

The home was clean, well maintained, and people were protected from the risk of cross contamination and the spread of infection. Staff had access to personal protective equipment (PPE) and received training in infection control. Equipment used within the home was regularly serviced to help ensure it remained safe to use.

People were aware of how to make a complaint and felt able to raise concerns if something was not right. The provider and manager welcomed comments and complaints and we saw where concerns had been received these had been investigated in line with the homes policy and procedures. People, relatives, and staff spoke positively about the leadership of the home and told us the home was well managed. People said the home had improved since the new manager had taken over. People told us they were encouraged to share their views and the provider employed the services of an external company to regularly seek the views of people and their relatives.

The manager was aware of their responsibilities in ensuring the Care Quality Commission (CQC) and other agencies were made aware of incidents, which affected the safety and welfare of people who used the service.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

We carried out a previous inspection of this service on 10 May 2016 where we identified breaches of regulation. We found improvements were required in relation to the management of medicines, in relation to following specialist guidance, records management and the quality assurance systems. At this inspection on 7 and 10 February 2017, we found some action had been taken to respond to our concerns in relation to medicine management, but found action was still required to further improve this, and we identified other areas of concern.

This inspection took place on 7 and 10 February 2017 and the first day was unannounced. At the time of our inspection there were 20 people living in Willow House. People had a range of needs, with most people at the home living with a form of dementia.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The timing of this inspection was brought forward following a number of safeguarding concerns as well as information of concern being received. These concerns related to people not being cared for safely, one person having their call bell taken away by staff, people’s individual needs not being responded to and people not being treated with respect. We found evidence of most of these concerns during our inspection but did not find any evidence of staff failing to treat people with respect.

Since May 2015 Willow House has been inspected four times and at each of these inspections we found breaches of regulation and the service was rated requires improvement. Although the provider was working hard to improve systems and practices at Willow House, concerns relating to people not always receiving safe care and treatment and quality assurance processes being ineffective at identifying concerns persisted. We found the systems in place to monitor the quality and safety of people’s care were not effective and had not identified significant issues.

People who lived in Willow House were not always safe. Sufficient action had not always been taken to protect people from the risks of harm. Risks to people had not always been identified and risk assessments were sometimes not completed, or did not provide any guidance on how staff were to minimise or manage risks. This included risks relating to falls, weight loss, seizures, suicidal thoughts, aggressive behaviours and people’s behaviours which could pose risks to themselves.

The registered manager, senior management and staff did not have a good understanding of the Mental Capacity Act 2005 (MCA). Where one person who had capacity to make decisions, had expressed their wish for bed rails not to be used on their bed. We found that bed rails were regularly being used on their bed. There was no evidence this person’s consent had been sought and recorded when these had been used.

People did not always receive care which was person centred and reflected their individual needs. People’s care plans did not always contain sufficient detailed information for staff to meet people’s needs. In one instance, a person did not have a completed care plan after having been living in the home for a period of almost seven weeks. This person had specific needs relating to their personal care and staff had not been instructed on how to meet these needs. Records showed this person’s needs had not been met in the way they required on a number of occasions.

The systems in place for assessing and monitoring the quality and safety of the care at the home had not been effective in identifying the issues we found during the inspection. The quality assurance systems did not look at people’s care or risk management and simply checked records and charts for potential gaps. Although charts had been checked, concerns identified within these had not been picked up for. For example, food charts were being checked weekly but had not identified that one person was eating a pureed lunch and snacks which consisted of biscuits, sandwiches and pasties. This issue had not been looked at and therefore it had not been identified that no specialist guidance had been sought for this person in a number of years and that original guidance which had been shared by word of mouth was not being followed either.

People, relatives and staff spoke highly of the registered manager and told us they provided visible, approachable leadership. Staff told us the registered manager picked up on poor practice and led by example.

Although improvements had been made in relation to records and these were regularly checked as part of the auditing system, we found records for people were not always accurate or up to date.

Recruitment procedures were in place to ensure people of good character were employed by the home. Staff underwent Disclosure and Barring Service (police record) checks before they started work in order to ensure they were suitable to work with people who were vulnerable. Staffing numbers at Willow House were sufficient to meet people’s needs and provide them with individual support.

Staff treated people with kindness and respect. Although prior to our inspection we had received information of concern relating to the culture in the home and the demeanour of staff, during our inspection we saw positive and caring interactions between people and staff. We found staff had caring attitudes towards people and provided people with affection and humour. Staff knew people’s needs, preferences, likes and dislikes and spoke about people with respect and admiration.

People were supported to make choices about what they wanted to eat and food was presented in ways which met people’s individual needs. People told us they enjoyed the food.

In light of some of the significant concerns we identified relating to people’s safety, we made alerts to the local safeguarding team. Since the inspection the local safeguarding team and the local authority have been working with the provider.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to people not always being protected from harm, people’s rights being restricted, staff not following the principles of the MCA, people’s care not always meeting their needs, ineffective quality assurances processes and people's records not always being accurate or up to date.

We are considering our actions in line with CQC's enforcement policy. We will publish a further report that details what action we have taken at a future date . Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

This inspection took place on 10 May 2016 and was unannounced. At the time of our inspection there were 19 people living in the home. People had a range of needs with some people being more independent than others. Some people had significant needs relating to their health and mobility.

We carried out a previous focused inspection of Willow House on 26 November 2015 and identified some concerns. These related to risks to people not always being identified and acted on, medicines not always being managed safely, people not always being treated with dignity and respect, records not always being accurate and systems in place to monitor the care provided not being effective. At this inspection in May 2016 we found the registered manager and the provider had worked hard to improve the service. A lot of improvements had been made and some of the issues previously identified had been rectified. However, we did identify some concerns that still needed addressing.

People were not safe from risks relating to the management of medicines. One person had one specific medicines hand written three times in their medicine administration record along with two different instructions which would have caused confusion for staff. Staff had not always recorded how many tablets people had been administered when these were variable. There was a lack of guidance in people’s care plans and in the home relating to PRN (when required) medicines used to treat anxiety and agitation. This could pose risks of people receiving medicines when they did not need them or not receive them when they did.

People’s records were not always accurate or up to date and were sometimes confusing. For example, staff had recorded three different weights for one person on their fluid intake records which changed the target amount of fluid they should be having. Another person had significant gaps in the recording of their regular repositioning in order to reduce the likelihood of damage to their skin. The processes and systems in place to monitor, assess and mitigate the risks to people had failed to identify the concerns we found during our inspection. Although audits and checks were in place these had not been effective in identifying issues and mitigating risks.

Where specific guidance had been sought from specialist professionals in relation to people’s eating and drinking, we found this guidance had not always been followed by staff. We made a recommendation that, where specialist advice was provided this was followed in order to ensure people were receiving care which followed best practice.

Following our inspection in November 2016 the service had signed up to an initiative called Dementia Care Matters which aims to improve the care home experience for people living with dementia. The registered manager, the directors and the staff spoke with obvious enthusiasm about the changes they were implementing at the home and how these were benefitting people.

Work had gone into improving the environment at Willow House and further work was planned. The atmosphere in the home was warm and welcoming and the home was decorated in a way that felt homely. Thought had gone into the layout of the living rooms and the dining room and changes had been made to enable people to move around independently where possible.

People were being supported to take part in activities which helped them regain and retain independence skills, such as taking part in housework, making teas and coffees for people and helping fold laundry. Organised activities such as games and musical guests also took place and staff spent time sitting and chatting with people on an individual basis.

There were enough staff at Willow House to care for people in the way they needed and spend time with people at their own pace. There were safe staff recruitment procedures in place to ensure staff hired were of good character. Staff received regular training to make sure they knew how to meet people’s needs and staff were supported through the use of supervisions, observations and appraisals. At the time of our inspection the supervision process revolved around staff performance and did not enable staff to discuss their views and opinions as much as needed. We raised this with one of the directors who told us the registered manager would be making changes to the supervision format once they were confident good staff practice was fully imbedded.

There were processes and checks in place to ensure people were cared for in a safe environment. There were plans in place to protect people and deal with foreseeable emergencies. Staff had received training in safeguarding people and knew how to recognise and report signs of possible abuse.

People were supported to eat and drink enough to maintain good health. People were offered a choice of meals to meet their preferences and meals looked appetising. Mealtimes were social events with staff encouraging conversations between people.

Most people who lived in Willow House had been assessed as not having the mental capacity to make certain decisions at certain times. Staff had received training in, and understood the principles of the Mental Capacity Act 2005 (MCA) and the presumption that people could make their own decisions about their care and treatment. Following our previous inspection in November 2015 the registered manager had sought training, guidance and support in relation to the MCA and the Deprivation of Liberty Safeguards (DoLS). They spoke enthusiastically about their learning and how they were applying it.

People were supported by kind and caring staff. Comments from people included “The staff are lovely”, “They’re all as good as gold”, “You couldn’t fault them” and “Oh yes they talk to me nicely”. The registered manager told us about staff’s caring attitudes and gave us examples of the staff going above and beyond for people. They told us about staff staying on after their shifts to help decorate the home, in order to make it more homely for people, create music compilations people would like or altering and fixing people’s clothes for them.

People’s needs had been assessed prior to them moving into the home. Each person had a care plan which had been developed by staff with their and their relatives’ input. These care plans contained information about each person’s needs and how staff should meet these. Staff knew people well and understood their personalities, sense of humour, likes and dislikes. Staff spoke confidently about people’s individual care needs and how they met these.

The home had a complaints procedure displayed along with contact numbers for people to call if they were unhappy. Staff encouraged people to share their views. Staff, relatives and healthcare professionals told us they had confidence in the registered manager and felt they would listen and act appropriately if a complaint was made. The service was open and encouraged staff and people to share their views.

Work was being undertaken to improve the quality of care people were receiving at Willow House. Where ideas had been suggested, concerns had been raised or feedback had been given, action had been taken.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to people not always being protected from harm and people’s records not always being accurate or up to date. You can see what action we told the provider to take at the back of the full version of this report.

People told us they were treated with respect and we witnessed this during our inspection.

Staff knew about recognising and preventing abuse. They had a good understanding of the different types of abuse and were able to correctly describe the procedure to be followed if they suspected or witnessed any. People told us they felt safe and that care workers were very caring. One person said 'I watch what goes on. I have never seen the staff show anything but kindness.'

The feedback about staff from people who lived at the home, relatives and health care professionals was very good. Staff were described as being 'kind', 'caring' and 'delightful.' There was a stable staff team who cared for people at the home. People told us they thought there were enough staff on duty. Staff told us there had been some instability in the staffing but this had settled now leaving a 'good team of staff.'

There was an effective system in operation which was designed to enable the provider to regularly assess and monitor the quality and safety of the services provided.