The Willows Nursing Home

Updated 2 September 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was undertaken by 1 inspector, a specialist advisor and an Expert by Experience who undertook phone calls to relatives. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. The specialist advisor was a nursing professional.

Service and service type

The Willows is a care home. People in care homes receive accommodation and nursing and personal care as a single package under one contractual agreement dependent on their registration with us. The Willows is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 27 June 2023 and ended on 17 July 2023 when formal feedback was provided. We requested and reviewed records remotely during this period. We visited the service on 27, 29 June and 6 July 2023. Phone calls were made to relatives on 30 June by the Expert by Experience.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.

We also used information gathered as part of the monitoring activity that took place in April 2023 to help plan the inspection and inform our judgements. We used all this information to plan our inspection.

During the inspection

We spoke with 7 people and 13 relatives about their experience of the care provided. We also spoke with 14 staff which included permanent and agency nursing staff, care staff, team leader, activities coordinator, kitchen assistant, domestic staff, deputy manager, and the registered manager. We also spoke with 2 health care professionals.

We reviewed a range of documents and records including the care records for 10 people, multiple medicine records, and 3 staff recruitment files. We also looked at records that related to the management and quality assurance of the service.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

Updated 2 September 2023

About the service

The Willows is a nursing home providing personal care and accommodation for up to 48 people across 2 floors. Each floor has its own communal areas. The service supports people with general nursing needs on the ground floor and people living with Dementia on the first floor. At the time of our inspection there were 38 people using the service.

People’s experience of using this service and what we found

Improvements were still being made to develop effective systems to monitor the care provided to people and to ensure people’s records reflected their needs. These systems were being reviewed and amended but needed further time to be embedded to help drive improvements in the home. The registered manager demonstrated a commitment to delivering improvements and had an improvement plan in place which was updated to include the feedback we shared during and following our inspection.

Systems were in place to review incident and accidents, and action was taken to learn lessons from these. This included a recent incident where action has been taken to reduce the risks of this event happening again. Improvements were made during the inspection to increase staffing at peak times during the day to ensure people received the support they needed.

People were supported by staff who had been recruited safely received training and understood how to protect people from abuse. People received their medicines when they needed them. People had access to healthcare professionals to ensure their healthcare needs were monitored and met.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People and those important to them, were involved in planning their care and were supported to provide feedback about the way the service was managed. People and their loved ones were happy with the service provided and felt able to approach staff and the registered manager.

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

Rating at last inspection and update.

The last rating for this service was requires improvement (published April 2019.) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

The service remains rated requires improvement. This service has been rated requires improvement for the last 3 consecutive inspections.

Why we inspected

This inspection was prompted by a review of the information we held about this service. It was also prompted in part due to concerns following an incident where a person had developed sore skin. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We found no evidence during this inspection that people were at risk of harm from this concern. The provider had taken action to mitigate the risks, and this had been effective.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service remains requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, and well led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Willows nursing home on our website at www.cqc.org.uk.

Enforcement

We have identified a breach in relation to the overall governance of the service. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.