Archived: The Willows Care Centre

At the last inspection we found continued breaches of regulations 12, 17 and 18 of the Health and Social Care Act 2008 and the service was rated Requires Improvement. Following the inspection, we asked the provider to complete an action plan to show what they would do and by when to address the breaches. At this inspection we found that the provider had completed their action plan and the service was no longer in breach of regulations.

Since our last inspection the provider had completed their plan to stop providing nursing care at The Willows Care Centre. People who required nursing care had been supported to move to alternative services and the provider no longer employed registered nurses.

At our last inspection in August 2017 we found people were at risk of harm because their medicines were not managed safely. At this inspection we found that significant improvements had been made to the management of people’s medicines and people were no longer at risk.

People were now protected from the risk of harm. Previously risks to people had not been assessed and action had not been taken to mitigate risks. Risks had now been identified and action had been taken to manage them.

Records about people and the care they received were now accurate and complete, held securely and easily accessible to staff when they needed them. The provider had addressed the shortfalls in the record keeping and storage found at our last inspection.

Previously effective systems to assess, monitor and improve the quality and safety of the service were not in operation. Since our last inspection the provider had improved the checks completed at the service and now had oversight of the service. The registered manager and the provider checked all areas of the service regularly to make sure it met the standards they required. Any shortfalls had been identified and action was planned and completed to address them. The views of people, their relatives, staff and community professionals were asked for and acted on to continually improve the service.

A registered manager was leading the service. 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.

Staff felt supported by the registered manager and were motivated. A member of the management team was always available to provide the support and guidance staff needed. Staff worked together to support people to be as independent as they wanted to be. All the staff we spoke with told us they would be happy for their relatives to live at The Willows Care Centre.

Staff were kind and caring and treated people with dignity and respect. They took time to get to know each person well and provide the care people wanted in the way they preferred. People received the care and support they wanted at the end of their life. Since our last inspection the provider had begun to implement the Gold Standards Framework (GSF) for end of life care. The GSF is a recognised approach to ensuring that everyone receives appropriate and individualised care which takes account of their wishes and preferences at the end of their life.

Assessments of people’s needs and any risks had been completed and care had been planned with them, to meet their needs and preferences and keep them safe. Accidents and incidents had been analysed to look for patterns and trends. The registered manager worked in partnership with local authority safeguarding and commissioning teams, and a clinical nurse specialist for older people and acted on their advice to develop the service and improve people’s care.

Staff knew the signs of abuse and were confident to raise any concerns they had with the registered manager or provider. People were not discriminated against and received care tailored to them. A process was in operation to investigate and resolve complaints to people’s satisfaction. People had enough to do during the day, including activities to keep them physically and mentally active.

Changes in people’s health were identified and people were supported to see health care professionals, including GPs when they needed. People were offered a balanced diet of food they liked and that met their cultural needs and preferences. Staff supported people to be as independent as they wanted at mealtimes.

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. The registered manager knew when assessments of people’s capacity to make decisions were needed. Information was available to people in a way their understood to help them make decisions and choices. Staff treated people with dignity and gave them privacy. The registered manager understood their responsibilities under Deprivation of Liberty Safeguards (DoLS), and had applied for authorisations when there was a risk that people may be deprived of their liberty to keep them safe.

There were enough staff to provide the care and support people needed when they wanted it. New staff were recruited safely. Disclosure and Barring Service (DBS) criminal records checks had been completed to make sure staff were suitable for their role. Staff were supported meet people’s needs and had completed the training they needed to fulfil their role.

The service was clean and staff followed infection control processes to protect people from the risk of infection. The building was well maintained and plans were in operation to maintain and improve the environment. People were able to use all areas of the building and grounds and were encouraged to make their bedroom feel homely.

The registered manager had informed CQC of significant events that had happened at the service, so we could check that appropriate action had been taken.

Services are required to prominently display their CQC performance rating. The provider had displayed the rating in the entrance hall and on their website.

Further information is in the detailed findings below.

At the last inspection, the service was rated Inadequate. The provider took prompt action to reduce the risks at the service. We took enforcement action against the provider and applied a condition to their registration requiring them to send us an action plan twice each month informing us how they were improving the quality and safety of the service. We received these actions plans as required. At this inspection we looked to see if the action taken by the provider had been effective and found that improvements had been made. However, there were continued breaches of four regulations and further improvements were required in other areas.

Before our inspection the provider decided to stop providing nursing care to people. They were working with the people, their families, funding authorities and the local Clinical Commissioning Group to assess each person’s needs to make sure they could continue to be met at the service. Plans were in place to support people who required nursing care to find alternative services.

A manager was working at the service. They had applied to be the registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the care and has the legal responsibility for meeting the requirements of the law. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

The provider’s oversight of the service had improved since our last inspection. The support provided to staff had increased, however nurses had not always been held fully accountable for their responsibilities. A number of checks and audits had been completed; however, action had not always been taken to address any shortfalls found, including medicines errors.

Some staff continued not to follow the provider’s medicines procedures and people continued to be at risk from unsafe medicines management, including the safe storage and administration of medicines.

At our last inspection we found that risks to people had not been consistently identified, assessed and reviewed. At this inspection we found that some risks, including risks to people’s skin, continued not to be assessed and reviewed regularly. Care had not been planned to meet people’s changing needs, including the correct use of pressure relieving equipment. Other risks, such as the risk of people losing weight or falling had been assessed and action had been taken to keep people safe.

The provider’s recruitment procedures had still not been followed for all staff. The Disclosure and Barring Service (DBS) criminal records check for one staff member had not been fully completed and disclosures on another DBS had not be adequately assessed. The DBS helps employers make safer recruitment decisions and helps prevent unsuitable people from working with people who use care and support services.

People were not always treated with respect. People continued not to have enough to do during the day on occasions, despite care staff spending more time with people and inviting outside entertainers into the service. We have made a recommendation about activities for people living with dementia.

Some confidential information about people had not been disposed of securely. Some records about people’s care had improved. However, detailed and up to date guidance was not available to staff about some people. The management team had recognised this and put plans in place to address the shortfalls. Records were now accessible to staff.

Previously we found that staff did not know the signs of possible abuse and safeguarding risks had not been identified and acted on. Staff had completed training since our last inspection and knew the signs of abuse. Any concerns had been recognised and discussed with the local authority safeguarding team.

Since our last inspection staff had completed training about how to keep people safe in an emergency. Following our last inspection the local Fire and Rescue Service had visited the service and the provider had acted on their advice.

People now received the care they needed to keep them as healthy as possible. Previously people were not always offered foods to help keep them as healthy. At this inspection we found people were offered food and drinks to meet their needs and preferences, including cultural and spiritual preferences.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Applications had been made to the supervisory body for a DoLS authorisation when people were restricted.

Some staff had completed training in relation to the principles of the Mental Capacity Act 2005 (MCA) since our last inspection. Assessments had been completed of people’s capacity to make specific decisions and people were supported to make day to day decisions. Further improvements were planned to support people to understand and make choices.

There were now sufficient staff deployed to meet people’s needs and people no longer had to wait for the support they needed. Since our last inspection staff had completed training in key areas including dementia care and communication. Staff told us they now felt supported by the management team. Staff had not met regularly with a manager to discuss their role and practice. The management team had identified this shortfall and a plan was in place to address this.

Staff now worked as a team and knew about their roles and responsibilities. Staff told us they felt appreciated by the management team and the provider and were motivated to continue to improve the service.

Since our last inspection the provider and manager had recognised, investigated and resolved complaints they received. Complaints and concerns had been used to improve the service.

People and their relatives and staff were now involved in planning what happened at the service and had been asked for their feedback. A residents and relatives group had been established and a representative regularly met with the manager and provider.

We have received notifications of significant events that had happened at the service promptly since our last inspection.

We found a number of continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see the action we have told the provider to take at the back of the full version of the report. Following our inspection the provider sent us an action plan detailing how they would address the concerns identified during the inspection. We will follow this up at the next inspection.

Provide a brief overview of the service (e.g. Type of care provided, size, facilities, number of people using it, whether there is or should be a registered manager etc).

N.B. If there is or should be a registered manager include this statement to describe what a registered manager is:

‘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.’

Give a summary of your findings for the service, highlighting what the service does well and drawing attention to areas where improvements could be made. Where a breach of regulation has been identified, summarise, in plain English, how the provider was not meeting the requirements of the law and state ‘You can see what action we told the provider to take at the back of the full version of the report.’ Please note that the summary section will be used to populate the CQC website. Providers will be asked to share this section with the people who use their service and the staff that work at there.

At the last inspection, the service was rated Good.

The inspection was prompted by a number of concerns raised by whistleblowers, people’s relatives and local authority commissioning and safeguarding staff. The concerns included a lack of leadership, people not receiving care to meet their needs, poor medicines management, people’s complaints not being acknowledged and acted on, reduced staffing levels, staff not having the skills to meet people’s needs, poor working relationships between staff and poor or inaccurate records.

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

The registered persons did not have oversight of the service. They had not supported staff to provide a good level of care or held them accountable for their responsibilities. A care consultant’s audit in October 2016 had identified a number of shortfalls in the service that we found at the inspection. Action had not been taken to improve the service following this audit.

People were not always treated in a kind and caring way and were not always treated with respect. For example, one person was given their medicine in some yoghurt while they were eating a savoury meal.

Some staff did not know the signs of possible abuse. Safeguarding risks had not been identified and referred to the Kent local authority safeguarding team for their consideration or investigation. Some staff had contacted the Kent local authority safeguarding team and CQC about concerns they had about the care people received.

Risks to people had not been consistently identified, assessed and reviewed. Action was not always taken to reduce risks. Detailed guidance was not available to staff about how to keep people safe.

Staff did not have the skills and guidance they required to keep people safe in an emergency. Following our inspection we informed the local Fire and Rescue Service about the risks we found.

Care had not been provided to keep people as healthy as possible. For example, care had not been planned for one person following an injury and treatment at the local hospital. Nurses did not follow the provider’s medicines procedures to protect people from the risk of unsafe medicines management, including the safe storage and administration of medicines.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Applications had been made to the supervisory body for a DoLS authorisation when people were restricted.

Staff did not follow the principles of the Mental Capacity Act 2005 (MCA). Assessments had not been completed of people’s capacity to make specific decisions. People were not consistently supported to make day to day decisions.

People did not have enough to do during the day. Their interests and preferences had not been considered when staff planned activities. One person told us they were lonely in their bedroom and had nothing to do or listen to.

People told us they liked the food at the service and portions sizes had increased following their complaints. People were not always offered food to help keep them as healthy as possible. Meal times were not planned to make sure that people had regular meals spread throughout the day.

People were not protected by safe recruitment procedures. Disclosure and Barring Service (DBS) criminal records checks had not been completed for all staff before they began working unsupervised with people. The DBS helps employers make safer recruitment decisions and helps prevent unsuitable people from working with people who use care and support services. Potential risks to people from staff had not been assessed and action had not been taken to manage them.

People had to wait for the care they needed, for example, support to eat or have a wash. The registered manager had not made sure sufficient staff were deployed at all times to meet people’s needs.

Staff had not completed training in key areas or to make sure they had the skills to provide effective care to everyone, such as how to support people with mental health needs. Some staff told us they did not feel supported. They did not meet regularly with the registered manager or team leader to discuss their role and practice. Concerns about staff practice had not been addressed with them.

Complaints made by people and their relatives made had not been recognised. They had not been resolved to people’s satisfaction or used to improve the service.

People and their relatives, staff and other stakeholders such as GP’s had not been asked for their feedback on the quality of the service to help the provider identify shortfalls and continually improve the service.

Staff did not maintain accurate records about the care people received. Information was not available to staff and health care professionals to help them identify any changes in people’s needs. People’s personal information was stored safely.

The registered manager had not notified CQC of significant events that had happened at the service. Services that provide health and social care to people are required to inform the CQC, of important events that happen in the service like a serious injury or safeguarding concerns. This is so we can check that appropriate action had been taken.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see the action we have told the provider to take at the back of the full version of the report. During and after the inspection, the provider took action to start to put things right and to improve the care and support for people. They engaged with the local authority and employed a consultant to help improve the service for people. Following our inspection they sent us an action plan detailing how they would address the concerns identified during the inspection. We will follow this up at the next inspection.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking staff and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

We were made aware of concerns that people's needs may not be being met. Our inspection found the service was safe.

Care plans were regularly updated and included guidance for staff about how to support a person's needs and preferences. The service had a pre-admission procedure which included an initial assessment of people's needs. Potential risks to people were identified, assessed and managed. People's care plans and risk assessments were reviewed regularly to check they were still up to date. Spot checks were carried out that ensured that changes of needs were re-assessed and care plans were adjusted to reflect any changes.

The service acted in people's best interests and had consulted with relatives / friends or advocates where people lacked capacity or had partial capacity. Deprivation of Liberty Safeguards (DoLS) assessments had been completed, when needed to protect people's human rights.

People were supported to attend health appointments, such as, doctors or dentists. We saw records to show that the service worked closely with health and social care professionals to maintain and improve people's health and well-being.

The outcome of our inspection based on existing evidence, our visit and discussions with relatives at the time did not raise any concerns about the quality of care at The Willows.

The people that used the service had dementia and therefore not everyone was able to tell us about their experiences. To help us to understand the experiences people hade we used our SOFI (Short Observational Framework for Inspection) tool. The SOFI tool allows us to spend time observing what is going on in a service and helps us to record how people spend their time, the type of support they get and whether they have positive experiences. Some people using the service were able to tell us about their experiences and we also spoke with visiting relatives to the service.

We observed people expressing their opinions in a way that staff understood despite their communication difficulties. Staff had a good understanding of people's methods of communication and picked up on an individual's body language in order to support people in a way they preferred. We were unable to directly talk to all of the people who used the service due to their communication difficulties but observed that they were happy with the care and support being offered and that their independence was encouraged.

Relatives spoken with told us that the service responded to their relatives health needs quickly and that staff talked to them regularly about their plan of care and any changes that may be needed. People said staff were caring and treated them with respect. Relatives spoken with and observations made did not raise any concerns with regard to the quality of care received. All staff spoken with demonstrated experience and knowledge to enable them to support people who lived at the service with their needs.

People were cared for, or supported by, suitably qualified, skilled and experienced staff. There was a clear recruitment procedure. Appropriate checks were undertaken before staff began work.

Staff demonstrated, through discussion, that they had the skills to carry out their role. Records we viewed showed that staff had received training in core courses. Training updates had been carried out in line with current guidance as recommended by Skills for Care, a government training agency. Staff said they felt supported by the training to carry out their role.

We used a number of different methods to help us understand the experiences of people who used the service, because some of the people using the service had complex needs which meant they were not able to tell us their experiences. These included observing the care and interactions between the people and staff.

People told us that the service responded to their health needs quickly and that staff talked to them regularly about their plan of care and any changes that may be needed. People spoken with and observations made did not raise any concerns with regard to the quality of care received. All staff spoken with demonstrated experience and knowledge to enable them to support people who lived at the service with their needs..

We saw that the people who used the service were making choices about their lives and were part of the decision process. People had their own individual routines which were respected. One person who used the service said "staff are very good. I have no concerns". Another person said 'Food is great, lovely choices and plenty of it'. One other person who lived in the service said " If I was unhappy I would talk to the manager. My wife lives here. Staff look after her well. I have no concerns".

We observed 4 people in the dining room and also observed other people in other parts of the home. We noted that staff were polite and respectful in their interactions with people. There was an activity co-ordinator who asked if people wanted to go on a walk along the sea front that morning, and 2 of the people joined in the activity.

We spoke with 2 visitors, who told us that their relative was happy at the home, and 'settled well from the first day'. The visitors also told us that they were satisfied with the care received, and would not want to move their relative to another home.