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Inspection carried out on 12 January 2021

During an inspection looking at part of the service

Willows Edge is a care home providing personal and nursing care to people aged 65 and over. The service can support up to 39 people and on the day of our inspection there were 21 people living at Willows Edge, across three floors.

We found the following examples of good practice.

The service collaborated closely with multi-disciplinary teams and hospital discharge teams to ensure people were admitted into the home safely. Staff followed guidance to ensure visitors were prevented from catching and spreading infection. The registered manager openly shared information with friends and family about any infections, so they could understand decisions regarding visiting and any restrictions.

The provider was committed to ensuring the mental wellbeing of people during the pandemic, by enabling them to remain in contact with those who were important to them. For example, an internal, mobile perspex pod had been installed in a visiting room, only accessible through an external door, to reduce the risk of infection.

Staff worked with family members and community professionals to protect people identified to be experiencing low mood and anxiety, from the risks associated with social isolation. Effective partnership working with occupational therapists had promoted people's independence and increased their mobility. This helped to mitigate the risks of deconditioning occurring to frail, older people, whose normal activities had been curtailed by the pandemic.

People who were living with dementia experienced associated sensory impairments. Staff had collaborated effectively with the local authority Sensory Needs Team to implement additional/alternative resources to improve people's quality of life during the pandemic. Staff ensured effective communication was promoted and facilitated by using visual aids and prompts.

Staffing was maintained at a level significantly above that shown to be required by the provider’s staffing needs analysis. This enabled staff to be designated to specific floors and reduce the risk of infection. The provider also deployed additional contract cleaning staff, to concentrate on high risk and high touch areas, immediately following staff contact, to reduce the risk of infection.

The provider had worked effectively in partnership with the local authority clinical commissioning group (CCG). The registered manager had acted upon the recommendations and guidance of the CCG infection prevention and control specialist nurse, to improve standards of practice to keep people safe.

Inspection carried out on 27 February 2020

During a routine inspection

About the service

Willows Edge is a residential care home providing personal and nursing care to people aged 65 and over. The service can support up to 39 people and on the day of our inspection there were 30 people living at Willows Edge across three floors.

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

Staff understood their responsibilities to keep people safe from harm and people told us they felt safe. Care plans contained risk assessments and informed staff how to reduce the risk of harm to people. Safe recruitment procedures were followed and there was enough staff on duty to meet people’s needs. Medicines were managed safely. Incidents and accidents were reported, investigated and actions taken to prevent recurrence. The environment was clean, and staff followed infection prevention and control procedures.

People’s needs were assessed, and care plans were in place. People were cared for by staff who had been trained to carry out their roles and who were knowledgeable about the support people needed. People’s nutritional needs were assessed, and people were supported to have enough to eat and drink. People’s health needs were met. 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 spoke positively of the staff. Staff were kind and compassionate and interacted well with people. The atmosphere was relaxed, friendly and welcoming. People told us staff respected their privacy and dignity.

Care plans were person centred and included details of people’s preferences for how they wanted to be supported. Staff we spoke with were able to describe people’s care needs and preferences to us. People were supported to maintain relationships with family and friends. There was a range of activities for people to participate in if they wanted to. People’s feedback was sought. Complaints were reported, investigated and resolved appropriately

People we spoke with and healthcare professionals we spoke with all spoke highly of the service in general and the registered manager and the level of support and leadership they provided. There were quality assurance processes in place and an action plan for continual improvement.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was Good (published 12 September 2017).

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection carried out on 25 July 2017

During a routine inspection

Willows Edge is a residential care home for up to 39 people living with dementia. Accommodation is provided over three floors each served by a lift.

At the last inspection, the service was rated Good overall with a rating of Requires improvement for Safe, due to insufficient staffing provision.

At this inspection we found the service remained rated Good overall. Action had been taken to address the previous staffing issues through an increase in the service’s staff complement per shift. However, we found that further improvements were needed in “Effective” which was rated Requires Improvement. Further work was required to the general environment and to making the building and garden more dementia-friendly. Work had begun to address this but was still under way. Staff training and supervision had also fallen behind the provider’s own expectations but this too was being addressed since the appointment of a new registered manager in January 2017.

Previous issues with the food provided by the external caterers had been addressed and feedback said the food was improving.

The service had systems in place to ensure people were as safe as possible. Identified risks were assessed and action taken to mitigate them. Safety checks and servicing took place regularly and the staff recruitment process was robust.

The service met people’s needs effectively and responsively. People’s health and care needs were met. They were provided with a variety of activities and entertainment including some one to one time with staff. People’s and relative’s views about the service were sought and acted upon.

Care plans were sufficiently detailed for staff to be able to deliver personalised care. People were treated with respect and their dignity, privacy and rights were upheld. They were involved as much as possible in their care and making daily choices about their lives.

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 supported this practice.

The registered manager had effective systems to monitor the service and sought to develop and upskill the staff team. Staff felt supported and positive and understood the ethos of the service. Feedback from the local authority was positive. “Improvements have been noted around their documentation, recording/reporting and activities and [The registered manager] is currently addressing the environment.

Further information is in the detailed findings in the full report.

Inspection carried out on 28 & 29 April 2015

During a routine inspection

The inspection took place on 28 and 29 April 2015 and was unannounced. The service is registered to provide personal care support for up to 39 older people. At the time of the inspection care was being provided to 37 people all of whom were living with varying degrees of dementia. The home provided care over three floors, each with communal facilities available.

The service was required to have a registered manager. A manager was in place who had applied for registration. 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.

The service had been through a period without a permanent manager and where staff turnover had been high. This had resulted in training and staff support having fallen behind and reduced levels of activities at a time when dependency levels had increased.

The new manager was acting to address these issues and had sought additional care and activities staffing to do so. At the time of inspection staff levels were not sufficient to meet people’s needs at all times, which potentially placed them at risk of harm. Following the inspection plans were made to address this pending the recruitment of additional permanent staff.

People were supported with food and fluid intake and received their medicines correctly. Appropriate support was sought from external health professionals and others to support individuals and the development of the service.

Staff supported people in a caring way, involving them where possible and took account of their wishes. People’s rights and dignity were respected by the staff in the way their worked.

The operation of the service was monitored effectively by the manager and provider. Actions taken to address any issues were monitored.

Inspection carried out on 29 July 2013

During a routine inspection

We found that people�s consent was obtained wherever possible. They were given choices and helped to make as many decisions for themselves as they could. Relatives of people who used the service told us that staff were always willing to listen and respect people�s choices.

We found that people�s health and care needs were met. We saw staff responding to people�s requests for assistance promptly and in a patient and professional way. People indicated by nodding and smiling or told us that they liked living in the home.

People were given a choice of freshly prepared food. People told us the food was, ''very nice indeed''.

The home was clean, hygienic and well maintained and a major refurbishment programme was underway.

We found that there were enough staff who were trained and supported to give good care to the people who lived in the home. People described staff as ''lovely girls''. Relatives told us that ''staff were patient and professional''.

The home had ways of making sure that they checked the quality of care being given to people. They listened to the views of the people who lived in the home.

Inspection carried out on 11 December 2012

During a routine inspection

People who lived in the home told us that they were ��always treated with respect��. We found that staff communicated respectfully and sensitively with people who used the service, at all times. People told us that they could make choices about day to day activities for themselves and gave us some examples. We saw that staff respected people�s individuality and diversity.

We noted that the home was being refurbished in several areas. Staff were working hard to support the people who lived in the home through the disruption. The laundry refurbishment had been completed and the home had new windows. Staff members knew the individuals current needs and were observed meeting people's needs effectively. People told us that ��staff were always there to help you and always listened to what you told them��. Staff were supported to do their jobs by being provided with appropriate training and regular supervision. People described staff as ��very good� and relatives said they were ��very kind and caring��. We found that medication was being administered safely and any medication errors were dealt with appropriately.

The records kept in the home were accurate and up-to-date. They were kept securely and could be accessed by the appropriate staff members.

Inspection carried out on 6 January 2012

During a routine inspection

People told us that it was �quite nice� living in the home. They said there was very good food. People told us that �you could choose to do whatever you liked, for as long as you were still able to�.

A relative of someone who lived in the home described it as �brilliant�. They told us that staff were always alert to their relatives� needs. They said that when they left them they were confident that they would be well looked after.

Reports under our old system of regulation (including those from before CQC was created)