The Willows Care Home

Updated 22 April 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

This inspection was carried out by 2 inspectors.

Service and service type

The Willows Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. The Willows is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

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

Notice of inspection

This inspection was unannounced.

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. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 5 people and 1 relative. We spoke with 5 staff including senior care staff, care staff, the deputy manager and registered manager. We also spoke with the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We reviewed a range of records in relation to people's care, including medication records. We also reviewed a range of records held by the service including, staff training and rotas, recruitment records, audits and checks.

Updated 22 April 2023

About the service

Willows Care Home was providing personal care to 11 people aged 65 and over at the time of the inspection. The service can support up to 17 people in one adapted building.

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

Recruitment of new staff was not consistently robust. The provider took action to address these shortfalls. The provider’s systems for recruitment processes and environmental checks was not robust in identifying whether they were in line with current standards.

People told us they felt safe and supported by staff. Staff recognised different types of abuse and how to report it. The provider understood their safeguarding responsibilities and how to protect people from abuse. The provider had mitigated risk of harm and reported incidents to the local authority as required.

Potential risks to people's health and wellbeing had been identified and were managed safely. People, and where appropriate, their relatives, had been involved with decisions in how to reduce risk associated with people’s care. There were enough staff on duty to keep people safe and meet their needs. People's medicines were managed and stored in a safe way. Safe practice was carried out to reduce the risk of infection.

The manager was visible within the home and listened to people and staff views about the way the service was run. The provider had put checks into place to monitor the quality of the service provision.

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 (18 January 2022).

We carried out an unannounced inspection of this service in January 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to ensure safe care and treatment at all times, and to improve how they had sufficient staff to meet people’s needs, and to improve their governance systems.

We undertook this focused inspection to check whether the Warning Notice we previously served in relation to Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

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 has remained the same. This is based on the findings 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.

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

Enforcement and Recommendations

We have identified a breach in relation to recruitment of new staff and good governance at this inspection.

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.