Archived: The Willows

Updated 30 November 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 2 and 3 October 2017. The first day of the inspection was unannounced.

The inspection team consisted of one inspector and an Expert by Experience (ExE). An ExE is a person who has personal experience of using or caring for someone who used this type of service.

Before the inspection we reviewed the information we held about the home, in particular notifications about incidents, accidents, safeguarding matters and any deaths. We contacted the local Healthwatch group, the local authority contracts team, the local authority safeguarding adults team and the local clinical commissioning group. We used their comments to support our planning of the inspection.

We spoke with nine people who used the service to obtain their views on the care and support they received. We also spoke with eight relatives. Additionally, we spoke with the registered manager, two registered nurses, two care workers, two cooks and the home’s handyman. During the inspection we spoke with staff from the local Learning and Development Unit and the local Deprivation of Liberty Safeguards team.

We observed care and support being delivered in communal areas and viewed people’s individual accommodation. We reviewed a range of documents and records including; four care records for people who used the service, ten medicine administration records (MARs), three records of staff employed at the home, complaints records, accidents and incident records, minutes of meetings with people who used the service or their relatives and a range of other quality audits and management records.

Updated 30 November 2017

This inspection took place on 2 and 3 October 2017 and was unannounced. This was the first inspection of the home under its current name and with this provider. Sovereign Care (NE) Limited had previously been the provider at this location up until November 2015, when a different provider had taken over responsibility for the home. Sovereign Care (NE) Limited subsequently re-registered this location and changed the name to ‘The Willows’ in November 2016.

The Willows is a care home that can provide accommodation and personal care to a maximum of 27 people. It is registered to provide nursing care.

The home had a registered manager in place and our records showed she had been formally registered with the Care Quality Commission (CQC) since June 2017. 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.

People told us they were safe living at the home and staff had a good understanding of safeguarding adults procedures. We found a range of safety issues at the home including checks and certificates not in place for lifting equipment, gas safety and electricity safety. Maintenance of the premises had been undertaken, although records were not always maintained in a single location. People had emergency evacuation plans in place. Accidents and incidents were monitored, although up to date reviews were not always in place.

Suitable recruitment procedures and checks were in place, to ensure staff had the right skills. All staff had been subject to a Disclosure and Barring Service check (DBS). Some people and staff members told us there were times when more staff would be helpful, but overall there were enough staff at the home. We found minor issues with the management of medicines at the home, which were addressed immediately. Audit processes for the safe management of medicines were not always robust.

Staff told us they had access to a range of training and updating. Records relating to this were not readily available. The local Learning and Development Unit confirmed staff had accessed a range of online training. Annual appraisals had not yet been undertaken since to provider took over responsibility for the home. Staff told us, and records confirmed regular supervision took place. People told us, and our observations confirmed the home was maintained in a clean and tidy manner.

People’s health and wellbeing was monitored and there was regular access to general practitioners, dentists and other specialist health staff.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS are part of the Mental Capacity Act 2005 (MCA). These safeguards aim to make sure people are looked after in a way that does not inappropriately restrict their freedom. We found some people, who had previously had DoLS in place had not had this authorisation renewed or had not been reassessed to determine if it was still required. People were asked their consent on a day to day basis.

People were happy with the quality and range of meals and drinks provided at the home. They told us they could request alternative items. Special diets were catered for and kitchen staff had knowledge of people’s individual dietary requirements.

People told us they were happy with the care provided. We observed staff treated people patiently and with due care and consideration. Staff demonstrated a good understanding of people’s individual needs, preferences and personalities. People and relatives said they were always treated with respect and dignity. Relatives told us they were regularly involved in care decisions.

Care plans were detailed and related appropriately to the individual needs of the person. A range of activities were offered for people to participate in, although a dedicated activities co-ordinator was currently absent from the home.

The registered manager told us there had been one formal complaint in the last 12 months and this was being addressed appropriately. The majority of people and relatives told us they had no reason to raise concerns.

The registered manager told us regular checks on people’s care and the environment of the home were undertaken. However, these checks and audits were not formally recorded and had failed to identify the issues we noted at this inspection, particularly around safety issues and DoLS. The provider did not undertake a formal review of the home. Records were not always up to date or immediately available. Staff felt well supported by the registered manager, who they said was approachable and responsive. They felt additional management time or support would be useful. Staff told us they could raise issues or make suggestions and these were dealt with or acted upon. People and relatives told us the registered manager had made a significant impact in improving the home.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This related to the Premises and Equipment, Safeguarding people from abuse and improper treatment and Good Governance. You can see what action we told the provider to take at the back of the full version of the report.