The Willows

The Willows is a residential care home that provides accommodation and personal care for up to 39 people aged 65 and over, some of whom maybe living with dementia. At the time of this inspection 9 people were living at the service.

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

Whilst some improvements had been made in relation to the oversight and quality assurance at the service; the management team failed to ensure people were correctly safeguarded where concerns were identified. Appropriate action was not always taken in relation to allegations of abuse and the management team failed to follow their own safeguarding policy to protect people.

Infection control was not always promoted to ensure a safe environment. Areas of the service were odorous and some furniture did not support effective cleaning to take place. Safe infection prevention and control practice was not always promoted. There was a lack of clinical waste bins for staff to dispose of soiled incontinence aids and personal protective equipment was not stored appropriately.

Some improvements had been made to peoples care plans and risk assessments, however, further work was required. Records to support the monitoring of people’s health and wellbeing were not always accurately completed or provided staff with sufficient information to provide consistent care.

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 their relatives were happy with the care and support received. Relatives spoke positively about the improvements that had been made at the service. Staff were supported in their role and felt the management team was approachable.

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

Rating at last inspection and update

The last rating for this service was inadequate (published30 November 2022).

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.

At our last inspection we recommended that the provider monitored supervision and training of staff. At this inspection we found the provider had ensured staff were trained and supported.

This service has been in Special Measures since 20 December 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

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 is requires improvement.

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

Enforcement and Recommendations

We have identified breaches in relation to safeguarding, safe care and treatment and good governance at this inspection. We have made a recommendation regarding the safe recruitment of staff.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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.

The Willows is a residential care home that provides accommodation and personal care to people aged 65 and over, some of whom maybe living with dementia. At the time of this inspection 10 people were living at the service.

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

There continued to be concerns in relation to identifying and reducing risks, safeguarding people, staffing and oversight of the running of the service. A new manager had recently been employed and was committed to making changes, but enough improvement had not been made. A continued lack of oversight and support from the provider meant concerns had not been identified and progress was too slow. People remained at risk.

There were insufficient numbers of staff to meet people’s needs and keep them safe. Despite the registered manager being aware of risks within the service, these had not been taken into consideration when considering staffing levels. Following our feedback after the inspection, the registered manager confirmed they had reviewed staffing levels and increased these in the afternoon. People liked the staff who provided their care, but some people told us there was not enough of them.

Internal processes to safeguard people from the risk of abuse were not followed and placed people at risk. There continued to be a lack of oversight of safeguarding matters, accidents, incidents and lessons learnt.

Some additional training had been completed by staff. However, ongoing training was still required to ensure staff had the required skills to meet people’s individual needs. Staff had only recently been provided with supervisions by the new registered manager. We made a recommendation about this.

Medicines errors had reduced within the service; however, there continued to be some recording and process issues which had not been embedded in practice or identified as part of internal oversight.

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. From the information we reviewed, recruitment checks were in place.

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

Rating at last inspection

The last rating for this service was Inadequate (published 5 May 2021). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations and continues to be rated inadequate. This is the seventh consecutive inspection that the service has been rated below good and the third to be rated inadequate.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

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 inadequate.

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

Enforcement and Recommendations

We have identified breaches in relation to assessing risk and keeping people safe, safeguarding, staffing and governance.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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.

Special Measures

The overall rating for this service remains ‘Inadequate’ and the service is therefore still in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will act in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions, it will no longer be in special measures.

The Willows is a residential care home that provides accommodation and personal care to people aged 65 and over, some of whom maybe living with dementia. At the time of this inspection 14, people were living at the service.

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

There continued to be a lack of oversight and systems in place to drive forward improvements since the last inspection. Similar concerns were still identified in relation to medicines administration, risk management and good governance systems.

Infection control practices were not robust and placed people and staff at risk of spread of infection. Medicines continued not to be managed safely. Despite numerous assurances received from the provider about medicines management, errors were still identified which place people at risk of harm.

Staff continued to not receive adequate induction, training or supervision to ensure they had the appropriate skills and knowledge to support people. People continued to not always be safeguarded from the risk of abuse as oversight of these systems were not effective and the provider failed to take action when required.

Some 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. However, the policies and systems in the service did not always support this practice. The recommendation we made at the last inspection about this had not been fully met or embedded in practice.

Recruitment checks were in place, but we identified some gaps. We made a recommendation about this. The number of staff required was determined by a tool used by the provider. The tool had not been completed properly and the provider could not be assured they had a sufficient amount of staff in place. We made a recommendation about this. There continued to not be a registered manager in post. The previous manager left before the inspection.

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

Rating at last inspection

The last rating for this service was Inadequate (published 20 December 2021). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations and continues to be rated inadequate. This is the sixth consecutive inspection that the service has been rated below good.

Why we inspected

We received concerns in relation to the administration of medicines. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service remains inadequate. This is based on the findings at this inspection.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to medicines, assessing risk, infection control, health and safety staff training and support, safeguarding and governance.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures

The overall rating for this service remains ‘Inadequate’ and the service is therefore still in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions, it will no longer be in special measures.

The Willows is a residential care home that provides accommodation and personal care to people aged 65 and over, some of whom maybe living with dementia. At the time of this inspection 25, people were living at the service.

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

The service has failed to receive a good rating in the last five consecutive inspections. Systems in place had failed to improve the quality and safety of the service. There was insufficient oversight of this service with ineffective quality assurance systems in place which were not identify or driving forward improvements.

There was insufficient staff to meet people's needs and to ensure a safe, clean environment. This meant people had to wait for personal care and were left in communal areas for long periods of time without any staff presence.

Infection control procedures were not effective to reduce the risk of spread of infection during the COVID-19 pandemic. Medicines were not managed safely. Regular health and safety checks had not been carried out and risk management was not effective, placing people at risk of harm.

A lack of oversight of the recruitment processes meant processes were not always robust. Staff did not receive adequate induction, training or supervision to ensure they had the appropriate skills and knowledge to support people. People were not always safeguarded from the risk of abuse and oversight of these systems were not effective.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. We made a recommendation about this.

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

Rating at last inspection

The last rating for this service was requires improvement (published 14 May 2019). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations. This service has been rated requires improvement for the last four consecutive inspections. This inspection has been rated inadequate.

Why we inspected

We received concerns in relation to safeguarding people, staffing numbers and the administration of medicines. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from requires improvement to inadequate. This is based on the findings at this inspection.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to medicines, assessing risk, infection control, health and safety staffing, safeguarding and governance.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions, it will no longer be in special measures.

People’s experience of using this service: The plumbing and heating systems had been replaced apart from in one unit. This work was being undertaken. A separate dementia unit was about to be created to enhance the environment for people living with dementia. Infection prevention and control practices had been strengthened since the last inspection. Minor infection control issues found during the inspection were addressed. Medicine management had improved. However, staff were reminded not to leave medicines with people because they could be accessed by other people for whom the medicine was not prescribed.

The provider had failed to notify the Care Quality Commission about the absence of the registered manager. Timely action had not been taken to implement a recommendation made to improve the environment for people living with dementia. The replacement of the plumbing and heating system throughout the service had not yet been completed.

Safeguarding policies and procedures were in place to protect people from harm and abuse. Staffing levels were monitored to ensure people's needs were met consistently.

Staff received appropriate induction, training, and support and applied learning effectively in line with best practice. This led to good outcomes for people and supported a good quality of life.

Where people had been assessed as at risk from any activity, their care records provided guidance for staff to provide safe care and support.

Where people were unable to consent to their care and support the provider followed appropriate legislation to make sure any decisions were in the persons best interest.

People living at the service told us they were satisfied with the service provided. Staff understood the importance of providing person-centred care and developed positive relationships with people. People received support and staff encouraged their independence to live without unnecessary restriction.

Caring staff supported people living at the service. People received information in an accessible way to enable them to understand what was available to them.

Staff were trained and their skills and knowledge checked through competency assessments. Staff asked healthcare professionals for advice, guidance and support about how to meet people’s needs. People’s independence was promoted and encouraged. People’s dietary needs were met. End of life care was provided at the service. Concerns and complaints raised were dealt with appropriately.

The provider used a range of audits to check quality and safety at the service. These quality checks had been and were being improved to prevent further shortfalls occurring. For example, a laundry room audit was implemented during the inspection. Community links were being promoted. People and relatives had the opportunity to provide feedback about the service. Data security was maintained.

Rating at last inspection: At the last inspection the service was rated Requires Improvement (report published on 23 March 2018).

Why we inspected: This was a planned inspection based on the rating at the last inspection.

Follow up: We will continue to monitor this service and inspect in line with our re-inspection schedule or sooner if we receive information of concern.

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

At the last inspection of this service in December 2016 we rated this service as requires improvement in safe and well-led, which meant the quality rating of the service was requires improvement overall. There were no breaches of legal requirements.

At this inspection we looked to see if the required improvements had been made. We found the shortfalls found with the toilet and bathrooms at the last inspection had been addressed, however other shortfalls were found with the environment, infection control and medicine management and quality monitoring of the service. However we found the service was not always well-led and infection control and medicine management was not monitored effectively. The environment and heating systems at the service were also not well maintained. There was a breach of Regulation 17, Good Governance and Regulation 15, Premises and equipment of the Health and Social Care Act 2008 (Regulated Activities) 2014. You can see what action we told the provider to take at the back of the full version of the report.

The Willows is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission regulates both the premises and the care provided, and both were looked at during this inspection.

The care home accommodates up to 39 people across three separate units, each of which have separate facilities. The service provides care and support to people living with dementia. At the time of our inspection there were 18 people using the service.

There was a registered manager in place. 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 legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found there were issues with infection control, some of the issues were addressed at the time of the inspection. We recommend infection control is made more robust at the service.

We also found medicine management required improving in regard to the secure storage of medicine and in relation to the administration and recording of people's prescribed creams and ointments. We recommend medicine management is made more robust at the service.

We found staff were aware of how to report potential harm and abuse. This helped to protect people. Accidents and incidents were monitored and there was a robust recruitment process in place.

The environment in some areas was found to require enhancing to help support people living with dementia. Some areas of the service were decorated in bland colours with no highlighted features such as hand rails or bedrooms doors which may help people see them. There were highly patterned carpets in some areas which may confuse people living with dementia.

We recommend good practice guidance for dementia friendly environments is followed at the service.

Staffing levels provided were adequate to meet people's needs during our inspection. Staff undertook training and supervision. However, appraisals were not up to date and these were just being scheduled for staff.

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

People were treated with kindness and patience by staff and their privacy and dignity was respected. Advocates were available, if required to help people to raise their views.

A balanced diet was provided to people to ensure their dietary needs were met. People who required assistance to eat and drink were supported by attentive staff. Health care professionals supported people appropriately and help and advice was sought by staff in a timely way to help maintain people's health and wellbeing.

People’s care records were personalised and risks to their wellbeing were recorded, which informed the staff. People's preferences for their care and support and their communication needs were known by staff and were acted upon. There was a complaints policy and procedure in place. Issues raised were dealt with appropriately.

A roof required repairing and the heating system required replacing to ensure the home remained a pleasant place for people to live. The roof repair was about to take place. Fan heaters used throughout the service ensured people were not cold.

Staff meetings had not been held regularly, staff told us they could speak with the manager to raise their views at any time. We found one notification had not been sent in to the Care Quality Commission, the registered manager confirmed this was an oversight and addressed this shortfall.

People’s personal information was stored in line with the Data Protection Act.

We undertook this unannounced inspection on the 19 December 2016. At the last inspection on the 19 and 26 August 2015 we found a breach in regulation, which related to the operation of governance systems and auditing processes, and the availability of accurate and detailed records. The overall rating for the service was, “Requires improvement”. Following the inspection in August 2015 we received an action plan from the registered provider detailing how improvements would be made including a timescale.

The service had a registered manager in post who was also the registered provider. A registered manager is a person who has registered with the CQC to manage the service. 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 service is run.

At this inspection we found improvements had been made in regard to the continual evaluation of the actions required to improve the service and the accuracy and detail of records. The registered provider had made improvements in the way the service organised information and a programme of audits were in place to enable to the quality of the service to be monitored. An analysis of accidents and incidents was undertaken on a monthly basis to identify any trends or patterns.

At the last inspection we made a recommendation for the registered provider to find out more in relation to providing activities and meaningful occupation for people living with dementia. During this inspection we saw people were encouraged to take part in various activities if they wished to do so.

We found the service required improvements to two out of the five key areas at this inspection. We noted a number of maintenance issues that required attention at the service. These included toilet floorings lifting in areas, badly stained/marked toilets, plaster coming off wall and a cracked sink. We saw that two of the bathrooms had storage cabinets, which contained personal hygiene products, which should have been stored in the rooms of people who used the service to prevent cross contamination.

Staff understood the principles and processes of safeguarding vulnerable people and had received training to support them. People living at the service said they felt safe and told us that staff were good and caring. We found that medicines were stored and administered appropriately in line with current guidance. Staff had been recruited safely and appropriate checks were completed prior to them starting work at The Willows. Staff had good knowledge and an understanding of the needs of the people who used the service.

Plans were in place for emergencies like a fire or a flood and staff knew what to do in the event of an emergency. Safety equipment, electrical appliances and gas safety were all checked regularly.

The registered manager was following the principles of the Mental Capacity Act 2005 (MCA) although no applications had been submitted in respect of people being deprived of their liberty because this was not needed at the time of this inspection. The Mental Capacity Act 2005 (MCA) legislation is designed to ensure that when an individual does not have capacity, any decisions are made in the person's best interest and are least restrictive.

We observed that staff spoke to people positively and treated them with respect. Staff and people who used the service interacted in a friendly way and observations showed good relationships existed between them.

People who used the service had personalised care plans in place and their individual likes and dislikes were clearly documented. Risk assessments were in place together with information about people's life histories and medical conditions to help staff meet their needs.

People were given choices at mealtimes and they told us they enjoyed the meals. The atmosphere over the lunchtime period was calm and relaxed with laughter and conversation taking place.

Staff received regular supervision and an on-going training programme was provided to assist staff to increase their knowledge and skills.

There were systems in place to manage complaints and people who used the service told us they felt able to raise concerns and complaints.

The registered manager understood their responsibilities to report accidents, incidents and other notifiable incidents to the CQC as required.

We saw that people looked comfortable, well cared for and that staff interacted with them in a friendly and compassionate manner. People told us that staff listened to them and obtained medical assistance when this was needed. People told us that staff were helpful and 'Very kind.'

We observed staff interacted with people in an open and friendly way. People told us they were comfortable and felt safe in the home. People said they had 'No complaints' and would talk to staff in they had any concerns. There was evidence staff completed safeguarding training to ensure they were able to recognise and act on potential issues of abuse of people if this was required.

We found the home was warm, clean and well maintained. We saw a range of equipment was available such as walking aids and hoists, to enable peoples' personal dignity, independence and wellbeing to be promoted.

We found policies and procedures were followed for checking that staff were safe to work with people who used the service.

There were systems in place to enable the health, welfare and safety of people who used the service to be monitored by the provider. We saw letters of appreciation that had been recently received by the service.

We found there was a warm and friendly atmosphere throughout the home. We observed that people looked clean and well cared for and saw that the home was neat and tidy, with no unpleasant smells. Relatives we spoke with were very positive about the home, whilst a visiting district nurse told us they had 'No concerns' and were happy with service provided.

People told us that overall, they were happy with the standard of food that was served. We saw evidence of consultation with people about choices and suggestions for meals that were provided.

People who used the service told us they were 'Satisfied' and 'Confident" that any concerns would be properly dealt with. People told us they felt safe using the service.

Staff told us they enjoyed their work and we saw they worked effectively and efficiently as a team. We found that a programme of training was available to enable staff to undertake nationally recognised qualifications. People that used the service told us that staff were 'Fabulous.'

We saw that systems were in place to enable the quality of the service to be monitored by the provider.