Willowbank Nursing Home

Willowbank Nursing Home is a nursing home providing personal and nursing care to older people and people with a physical disability. The service can accommodate up to a maximum of 37 people. At the time of our inspection there were 29 people using the service. The nursing home accommodates people in one adapted building with bedrooms on the ground and first floor. The main communal areas are on the ground floor.

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

There were examples of safe practice but in general people were not safe. People were at risk of harm because the provider did not always identify or mitigate risks. This included risks relating to people's health and wellbeing, and environmental risks such as fire safety. Medicines were not always managed safely. Accidents and incidents were not always appropriately recorded. The service did not ensure staff had the time to give people the care they needed. Robust recruitment checks were not completed before staff started working at the service.

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. Systems were in place to safeguard people from abuse and control infection.

Services were not planned in a way that met people's needs. Care plans were not person-centred and did not always guide staff on people's current care needs. People’s preferences around end of life care were not known although the service did work closely with palliative care specialists to make sure people had a pain-free and comfortable death. Staff interacted with people in a kind and caring way. They described staff as ‘very caring’, ‘good’ and ‘courteous’.

There were widespread and significant shortfalls in the way the service was led. Complaints were not dealt with in an open and transparent way. Systems to assess, monitor and improve the service were not effective. The service had failed to respond to organisational risk such as fire safety concerns. There was a lack of effective leadership and management by both the provider and registered manager. The service had a range of systems which gave people opportunities to share their views and receive information. The service worked in partnership with health and social care professionals.

The provider was responsive to the inspection findings and sent information to show they were taking action to address the areas of risk identified at the inspection.

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 (published 9 February 2021).

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about the management of risks to people who used the service, medicines, staffing and complaints. A decision was made for us to inspect and examine those risks.

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 see what action we have asked the provider to take at the end of this full report.

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 changed from requires improvement to inadequate. This is based on the findings at this inspection.

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

Enforcement

We have identified breaches in relation to risk management, staffing, responding to complaints, person-centred care, recruitment of workers, medicines management 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 meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

We found the following examples of good practice.

We saw prominent and clear infection prevention control (IPC) signs reminded everyone at the point of entry and throughout the home about procedures for infection control.

The home was very clean. We saw evidence of cleaning records to support the cleaning process around the home.

Staff were seen to be correctly wearing personal protective equipment (PPE).

The home was accessing regular testing for both staff and residents. We saw evidence of this on inspection.

Risks in relation to visitors had been assessed and action taken to ensure visits were still in place at the service and through skype calls as well as window visits. The registered manager told us, “It is really important for people that they still continue to see or speak with their families.”

Staff said they had been well supported by the registered manager during the pandemic and had been kept up to date with all the Government changes in guidance. One member of staff said, “Yes our manager has been great, really supportive.” The registered manager went on to say how well the staff had continued to work throughout the pandemic.

Willowbank Nursing Home can accommodate up to 37 people who require support with nursing or personal care needs. At the time of our visit, 24 people were living at the service. [Insert a brief description of the building here].

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

The registered provider did not have effective governance systems in place to maintain and improve the quality and safety of the service. Analysis of accidents and incidents were very brief in detail and did not show any evidence to identify any patterns or trends.

Care plans were inconsistent, and we found some care plans were not accurate. We found people were not being weighed as frequently as directed by their care plan. One relative said, “I was relieved to have had the opportunity to correct some inaccuracies.” A staff member said, “They [care plans] are hard to understand and staff are writing information in different places.”

We found one person had bed rails in place, however no risk assessment had been completed for this. Fluid and repositioning charts were also inconsistently completed.

On the whole people received their medicines as prescribed. We found some areas of improvement were needed which was fed back to the manager on the day of inspection. For example, protocols were not always completed. Following the inspection this was added to the electronic system and sent to the inspector.

People and relatives told us they felt there were enough staff to support people’s needs and that staff were kind and caring. We observed people’s needs were met in a timely manner during this inspection. The manager provided us with evidence people’s dependency levels were used to allocate staffing.

People told us they felt safe and staff we spoke with had a good understanding of how to safeguard adults from abuse. Safe systems of recruitment were followed to ensure staff were safe to work with vulnerable people.

The home was clean throughout, with additional cleaning being completed during the COVID-19 pandemic.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 10 August 2018).

Why we inspected

This inspection was prompted in part due to concerns received about infection prevention and control, staffing levels, medicines and the management and governance of the service. A decision was made for us to inspect and examine those risks. We found evidence during this inspection that people were at risk of harm from some of these concerns, however we did not find evidence that harm had occurred.

This report only covers our findings in relation to the Key Questions of Safe, Responsive and Well-led which contain those requirements and concerns. 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 coronavirus and other infection outbreaks effectively.

Prior to the inspection we reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

We found evidence that the provider needs to make improvement. You can see what action we have asked the provider to take at the end of this full report.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.

We have identified breaches in relation to systems were either not in place or were not robust enough to demonstrate safety was effectively managed. This placed people at risk of harm. This was a breach of regulation 12 (Safe Care and Treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found no evidence that people had been harmed however, systems were either not in place or were not robust enough to demonstrate risks were effectively managed and comprehensive records were kept. This placed people at risk of harm. This was a breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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 the local authority and clinical commissioning group to monitor their progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Willowbank nursing home accommodates 37 people in one building and supports them with nursing or personal care support needs. At the time of our visit, 31 people were living at the service.

Willowbank Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service did not have a registered manager in place. The last registered manager deregistered on 6 June 2018. 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 provider’s peripatetic manager was present during the days of our visit. We will refer to the peripatetic manager in this report as the ‘manager’.

We previously carried out an unannounced comprehensive inspection of this service on 3 November 2015. At that inspection we rated the service as good. No breaches in regulations were identified at our last visit.

Staff were aware of safeguarding procedures and how to raise concerns. They had received training in this and outlined the types of abuse that could occur.

A range of audits were carried out by the registered provider to check on the quality of the service provided. These included 'walkarounds' undertaken by senior staff. These had not always been effective given that. For example, issues with the safety of the building had not always been identified.

Assessments for those coming to live at Willowbank Nursing Home covered all their main needs. Care plans were person centred indicating people’s personal preferences. Care records lacked specific detail about how people liked their support and contradictions in the support they received.

Staff had not always received supervision to support them in their role. Supervision records showed most staff had not received the number of supervisions as required by the providers policy. The temporary manager was aware of this and had made changes to the supervision system. We made a recommendation about the supervision process.

The premises was safe. Cleaning storage cupboards were kept locked and the environment was clean and tidy. Redecoration was taking place during the inspection to update some areas. The service had its electrical systems monitored and serviced for safe usage. The heating system ran on a bio fuel which was also serviced appropriately. Firefighting equipment was stored around the service for use in an emergency and a nurse call system was available in people’s rooms and communal areas.

People told us that they felt safe and that there was always staff around to attend to their needs. We observed staff had a constant presence in the communal areas of the service and people had their call bells answered and not left unattended.

New staff coming to work at Willowbank Nursing Home were recruited robustly with checks carried out to ensure that they were suitable to work with vulnerable adults.

Risk assessments were in place outlining the hazards faced by people from the environment. For example, risks faced in the support they received as well as risks faced by malnutrition or pressure ulcers. Emergency plans to aid the safe evacuation of people in an emergency were in place and reviewed regularly.

Medicines were robustly managed. Audits were in place to ensure that stocks never ran out and that people received the medicines they required. Staff had received training in medication administration. Medication was given to people in a supportive manner. Consideration had been given to enabling some people to partially self-administer their medication as an aid to encouraging independence.

The manager had measures in place to look at lessons learned. This was done in response to specific concerns within the service and whether these could have been responded to in a different and more effective manner.

Staff received the training they required to meet the needs of people. This related to mandatory health and safety topics as well as training in dementia care and safeguarding. Nursing staff were provided with training in clinical issues such as catheter care and tissue viability.

The registered provider worked within the principles of the Mental Capacity Act 2005. Applications had been made to the local authority identifying those people who required safeguards to partially deprive them of their liberty in line with their best interests and safety. There was evidence that people’s capacity had been assessed and that a best interests process had been followed to ensure that staff practice was mindful of people’s limitations.

The health needs of people were promoted with health professionals being routinely involved in dealing with health issues as well as routine health checks.

Staff adopted a caring approach when supporting people. Their approach was kind, friendly and informative. When people were distressed; staff adopted a patient and reassuring approach to assist people. Staff described how they would promote the privacy and dignity of people in their care practice. We observed this being adhered to.

The communication needs of people were considered. Effective arrangements to communicate with people with sensory limitations were in place. Advocacy was supported within the service with information signposting to local advocacy services available.

Information in relation to activities was accessible to those who used the service. The service befitted from an activities coordinator. Activities were observed during our visit and people were encouraged to take part. Activities coordinators had an extended role in assisting at lunchtime.

A complaints procedure was in place. Complaints had been recorded and investigated in line with the provider process.

People connected with the service such as health professionals, people who used the service and their families were given the opportunity to comment on the quality of support provided.

Staff commented that the manager was supportive and approachable and understood the needs of people. The manager was aware of their responsibilities as a registered person. This extended to notifying CQC of specific incidents and displaying the current CQC rating.

The inspection was carried out by an individual inspector. We looked at five specific questions; Was the service safe? Was the service effective? Was the service caring? Was the service responsive? Was the service well led?

Was the service safe?

Systems were in place to make sure that managers and staff learned from events such as accidents,incidents and complaints. This reduced the risk to people and helped the service to continuously improve.

When people were identified as being at risk, their care plans showed the actions that would be required to manage these risks. These included the provision of specialist equipment such as pressure relieving mattresses, hoists and wheelchairs.

The service had policies and procedures in place in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Staff received safeguarding and Mental Capacity Act training. This meant staff were aware of how to safeguard people as required.

There were sufficient care staff to respond to people's health and welfare needs.

Is the service effective?

People's health and care needs were assessed either with them or with their relative. From speaking with staff they were able to demonstrate a good understanding of people's care and support needs.

Suitable arrangements were in place for staff to receive updated training to ensure they had the skills, knowledge and experience to meet the needs of people who used the service. This ensured that the outcomes for people would continue to improve.

There was a resident's and relatives meeting at the home. This gave people the opportunity to discuss things that affected the running of the home.

Is the service caring?

We saw staff were attentive and respectful when speaking with or supporting people. The home had a relaxed and comfortable atmosphere. We saw that there was some good humoured banter between several people living at the home and staff. One person said, 'They (staff) are all wonderful.'

People looked well cared for and spoke highly of the care they received. We observed the lunchtime experience and saw that staff were calm and unhurried and they spent time with people.

Relatives we spoke with felt that overall the care and treatment provided was good. They told us they felt involved in their relatives care but felt that sometimes communication between staff wasn't very good. One relative told us, 'I tell staff something and it doesn't get passed on to staff on the next shift.'

Is the service responsive?

People's needs were assessed and records we looked at showed they received specialist equipment or aids that they needed.

People's preferences and interests had been recorded and care and support had been provided in accordance with people's wishes.

People we spoke with knew how to make a complaint if they were unhappy.

The service carried out an annual satisfaction survey. Results were collated and analysed and action plans were agreed and actioned. The results if the survey had been made available for people who used the service and visitors to the home to read.

Is the service well-led?

The service had a quality assurance system, and records showed that identified problems and opportunities to change things for the better had been addressed promptly. As a result we could see that the quality of the service was continuously improving.

Staff we spoke with were clear about their roles and responsibilities. This helped to ensure that people received a good quality service. They told us the manager and deputy manager were very approachable and supportive.

Effective management systems were in place to promote and safeguard people's safety and welfare. Such as health and safety records and peoples care records were up to date and had been reviewed regularly.

Relatives we spoke with told us they thought that overall the service ran well. One relative said 'Some of the staff here are very good.' Another relative felt able to talk to the staff about any concerns they had.

Staff were seen to interact well with people and knew them by their first name. There was choice in what people wanted to do and the privacy and dignity of residents was respected as we observed care interventions being carried out. Staff spoke to people in a very pleasant and dignified manner.

People said their rooms were clean and they were happy with the systems in place for their laundry. We found there were systems in place to reduce and protect people from the risks of infection. There were processes in place to promote the prevention and control of infections. One relative said, 'The place is always clean when I come.'

We saw on the day of our visit, there were enough qualified, skilled and experienced staff to meet people's needs.

The provider had a system for checking the quality and safety of the service and records were maintained and held securely.

'We are treated very well.'

'This is a nice place, everything is nice and the meals are very good.'

'I am very happy here; they do a good job for us.'

People we spoke with or their relatives said they understood their care and support plans and that staff had explained things well to them. People looked well cared for and supported and were responded to promptly when they asked for any support or assistance. We saw staff interacting with people in a respectful and caring manner. They showed warmth and patience when giving support to people.

People said their rooms were clean and they were happy with the systems in place for their laundry. However, we found the systems in place for the management of infection prevention did not always adequately protect people from the risks of infection. The processes in place did not always promote the prevention and control of infections.

People who used the service were very complimentary about the staff. Their comments included:

'I like them all, they are all so good to us.'

'Staff are very decent, very polite, that's what I like.'

People who used the service or their relatives said they were aware of how to make a complaint if they needed to do so. People said they felt confident to speak to the staff about any concerns they may have.