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Inspection Summary


Overall summary & rating

Good

Updated 17 December 2016

This inspection took place on 30 November 2016 and was unannounced.

The Willows provides personal care and accommodation for up to 30 older people and people living with dementia. On the day of our inspection there were 28 people using the service.

The Willows 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. 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 the time of our inspection a registered manager was in place.

During our previous inspection on 15 July 2015, we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was in relation to care not always being provided or delivered to meet people’s needs and the provider had not notified us of safeguarding incidents.

During this inspection we checked to see whether improvements had been made. We found improvements had been made and this breaches in regulation had been met. People received care and support that was personalised to meet their individual needs. The provider had notified us appropriately of any safeguarding incidents as required. .

Staff were aware of their responsibilities to protect people from avoidable harm. Staff had received adult safeguarding training and had available the provider’s safeguarding policy and procedure.

Risks to people's individual needs and the environment had not always been assessed. Concerns were identified with risks associated to a fish pond close to a door exist. The registered manager took immediate action and completed a risk assessment. Risks associated to people’s healthcare needs had not always been appropriately assessed and recorded. However, staff were aware of how to manage these risks; the issue was that of recording. The registered manager completed appropriate care plan documentation and risks assessments and forwarded these to us after the inspection.

Accidents and incidents were recorded and falls were analysed to review themes and patterns. External healthcare professionals were contacted to provide further assessment and support when concerns were identified.

Safe recruitment practices meant as far as possible only suitable staff were employed. The provider was recruiting additional staff but the deployment of staff was not consistent. The provider took immediate action and reviewed how staff were deployed. Appropriate adjustments were made to ensure people received the level of support they required to keep them safe at all times.

People received their medicines safely but some improvements were required to ensure the management of medicines followed good practice guidelines. The temperature of the medicines fridge was taken daily but not the medicines room. People’s records did not include information about how they liked to take their medicines. Protocols were not in place for medicines prescribed to be taken as and when required. The systems in place to audit that medicines were administered and managed safely were infrequent. The registered manager took immediate action to make improvements and after the inspection forwarded us information to confirm what action they had taken.

Staff received an appropriate induction, training and appropriate support.

The manager applied the principles of the Mental Capacity Act 2005 (MCA) and Deprivations of Liberty Safeguards (DoLS), so that people's rights were protected. Where people lacked mental capacity to consent to specific decisions about their care and support, appropriate assessments had been completed but improvements were required to ensure best interest decisions were made in line with this legislation. Where there were concerns about restrictions on people’s freedom and liberty, the manager had appropriately applied to the supervisory body for further assessment.

People received sufficient to eat and drink and their nutritional needs had been assessed and planned for. The menu showed that alternatives were available to the main meal option if required. People’s independence was promoted as fully as possible.

People's healthcare needs had been assessed and were regularly monitored. The provider worked with healthcare professionals to ensure they provided an effective and responsive service. External healthcare professionals were positive about how the service met people’s individual needs.

Staff were kind, caring and respectful towards the people they supported. They had a clear understanding of people's individual needs, routines and what was important to them.

The provider enabled people who used the service and their relatives or representatives to share their experience about the service provided.

People were involved as fully as possible in their care and support. The provider’s complaint policy and procedure and information about independent advocacy information was not on display for people. However, the registered manager took immediate action and forwarded us this information after our inspection to confirm this had been displayed for people.

People received limited opportunities to participate in activities, interests and hobbies of their choice. Staff provided activities daily when they could.

The provider had checks in place that monitored the quality and safety of the service. These included daily, weekly and monthly audits. Whilst the provider visited the service weekly, their checks on quality and safety and how they ensured the service was continually improving were informal. The provider assured us that they would develop formal systems and processes.

Inspection areas

Safe

Requires improvement

Updated 17 December 2016

The service was not consistently safe.

There were systems in place that ensured staff knew what action to take to protect people from avoidable harm. Staff had received safeguarding adult training.

Risks to people and the environment had not always been assessed and planned for.

The provider operated safe recruitment practices to ensure suitable staff were employed to work at the service. The deployment of staff was inconsistent.

People’s medicines had not always been correctly stored, managed or monitored effectively.

Effective

Good

Updated 17 December 2016

The service was effective.

Staff received an induction and ongoing supervision and training to enable them to effectively meet people’s individual needs.

The principles of the Mental capacity Act 2005 and Deprivation of Liberty Safeguards were understood by staff. Mental capacity assessments had been completed but best interest decisions not recorded.

People’s healthcare needs had been assessed and planned for. The service worked well with external healthcare professionals to ensure people’s healthcare needs were met effectively. People were supported to maintain a healthy and nutritious diet.

Caring

Good

Updated 17 December 2016

The service was caring.

Staff were kind, caring and treated people with dignity and respect and understood what was important to people.

People and their relatives were involved in decisions about their care.

People did not have access to independent advocacy information.

Responsive

Good

Updated 17 December 2016

The service was responsive.

People’s care plans provided some personalised information but this was lacking in parts.

People received limited opportunities to participate in activities and hobbies of their choice.

People were involved as fully as possible in their assessment and review of their care and support.

The provider had a complaints procedure but this was not accessible for people.

Well-led

Good

Updated 17 December 2016

The service was well-led.

Staff understood the values and aims of the service. The provider was aware of their regulatory responsibilities.

The provider had systems and processes that monitored the quality and safety of the service.

People, relatives and staff were encouraged to contribute to decisions to improve and develop the service.