The Willows

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has remained good.

This meant people were safe and protected from avoidable harm.

This service scored 78 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The registered manager recognised the importance of accurate record keeping, reporting of incidents and reflective learning. This was shared with staff, and the importance of good clear documentation was often discussed in supervisions and staff meetings. The organisation valued staff feedback at all levels. Staff reported they could contribute suggestions and ideas focused on improving the service. We saw a suggestion box encouraging staff to share ideas and feedback.

Where incidents such as falls occurred the serviced worked with the individual to find solutions and minimise risk. Discussions were held after incidents to share any lessons learnt with staff and to identify areas of improvement.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Staff worked well with external professionals to ensure people had their needs met and continuity of care. The service provides a lot of end-of-life care for people, and all staff have the “6 steps of end-of-life care” training, this ensured a smooth transition from hospital to the service.

Pre-assessments were completed by the registered manager and handed over to staff, staff told us they were comfortable contacting other healthcare professionals, for example GPs, physios or district nurses as required for advice and support.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Incidents were reported to both the local authority and Care Quality Commission (CQC) where appropriate in a timely manner. Staff understood their responsibilities and importance of reporting concerns. Staff had completed training in safeguarding and the Mental Capacity Act (MCA) and understood their responsibilities in supporting people who may lack capacity to make specific decisions.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider worked with people to understand and manage risks. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks to people were assessed and mitigated. Risk assessments were carried out for people with specific health conditions and were person centred. Care plans contained detailed information on how to support people to live safely, while enabling them to take positive and informed risks.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service had their own maintenance team to carry out any repairs reported by staff through the service electronic reporting system. The service had multiple types of equipment to assist people with moving and handling. We found these to be recently inspected and in good working order. Windows were fitted with restrictors. However, during the inspection we noticed some issues with windows in the service, for example one window did not close correctly enabling a draught in the room, and some window handles were loose. This was reported to the manager and rectified immediately following our feedback. The provider shared with us ongoing plans such as refurbishment of bedrooms and replacing furniture and flooring. There were also plans to create a new reception area in the entrance and to extend the conservatory lounge area. In addition, the garden was going to be refurbished in the summer.

The provider made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. They worked together well to provide safe care that met people’s individual needs.

There were consistently robust staffing levels in place, with an appropriate mix of skills and experience to meet people’s varying needs and levels of dependency. The provider also maintained a dedicated bank of carers, enabling people to be supported by familiar staff who knew them well and understood their routines, wishes and preferences. Throughout our visit, we observed that staffing levels were not only adequate but flexible and responsive. Senior carers, nurses and members of the management team were highly visible and actively involved in the running of the service. The registered manager led by example, demonstrating exceptional leadership and clinical excellence, and had created a strong, positive culture where high standards were embedded, consistently upheld and achieved.

Recruitment practices were robust and followed without exception. The provider operated a thorough and transparent recruitment process, ensuring that only individuals who were suitable and competent were appointed. Comprehensive pre-employment checks were completed, including interviews, references and Disclosure and Barring Service (DBS) checks, before staff commenced their roles. These procedures ensured people were supported by staff who were safe, trustworthy and well suited to working with individuals who may be vulnerable, fostering a strong culture of safety and professionalism from the outset.

Staff were well supported in their learning and development. They told us they felt valued and encouraged to continually develop their skills and knowledge and training was delivered through a combination of effective e‑learning and high-quality, practical sessions. There was a clear and well-planned programme of training scheduled throughout the year. We saw that staff were enrolled on various NVQ training programmes and support was given to international nurses to complete their training to be able to enable them to become a registered nurse in the UK.

The provider had implemented an innovative “Champion” scheme, where nurses, senior carers and carers were empowered to take lead roles in specific areas of care. This approach promoted ownership, reflection and continuous improvement. For example, the nutrition champion identified that some people requiring thickened fluids expressed a preference for cold drinks. They proactively explored this feedback and developed a safe method for preparing thickened lemonade, enabling people to enjoy a cold drink while maintaining their safety and dignity. This demonstrated a strong commitment to listening to people, responding creatively to their wishes and continually improving the quality of care provided.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The provider assessed and managed the risk of infection. They detected and controlled the risk and took appropriate action to prevent it from spreading and shared their concerns with appropriate agencies promptly. Staff were trained in relation to infection prevention and control (IPC). Personal protective equipment (PPE) stations were available in corridors around the service, and we observed staff wearing and using PPE. There were policies in place for infection control as well as a decontamination and infection control policy. The manager completed a monthly audit, and the service had a 98% score in a recent external IPC audit. During this assessment we observed that every area of the service was clean and tidy including all staff areas and the laundry room.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Medicines were found to be stored safely and securely and stock managed well, nurses and carers had good knowledge of this. Medicine stock balances were documented in places on medication administration charts (MARs). There were no discrepancies found. Controlled drugs were stored safely and securely with legible and accurate records. Medicines policies were in date and subject to a regular review. Staff were aware of the policies and received appropriate training on medicines.

Medicines that required storing in the fridge were kept appropriately and records of date of opening were clearly marked on liquids and eye drops. Temperature logs were in place and completed daily and no escalation due to temperature excursion had been required in the last month before assessment.

Processes were in place to ensure thickener was stored safely and used correctly. Staff demonstrated a sound awareness of people requiring thickener and charts were in place recording thickener administration.

Staff understood when to escalate concerns to the Speech and Language Therapy team (SALT) and followed the referral pathway where required. MAR charts, and charts for blood glucose monitoring and spacer device cleaning were well maintained.

PRN medication [medication used when needed] protocols were patient centred and up to date with review systems in place. Indications, alternative options prior to dosing, monitoring and dose intervals were clear. MAR charts clearly recorded the administration of medicines, including the reasons for administration and the outcome observed following each dose.

There were people that lacked capacity to agree to treatment had covert administration in place, this is a legally regulated action that disguises medication in food or drink given without the person knowing. Records showed best interest decisions regarding covert administration taking place.

There were also people receiving medication via a Percutaneous Endoscopic Gastrostomy (PEG) by nurses. Suitable training had been given to staff.

MAR charts had not initially recorded the route of administration via PEG. However, this was promptly corrected, which reduced the risk of errors or complications.

During this inspection it was found that flammable risk assessments were not in place for people who were prescribed topical medication such as creams and ointments. This included people who were smokers. Following our feedback these were put in place during the inspection and staff received appropriate training on flammable risk and the importance of completing adequate risk assessments.