Archived: The Willows Residential and Nursing Home

The Willows Residential and Nursing Home is a residential care home providing personal and nursing care. The service can accommodate up to 32 people in one adapted building. At the time of this inspection 30 people were using the service who had a range of needs including dementia and physical disabilities.

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

Some people, particularly those cared for in bed, felt lonely and isolated. Although staff told us activities were provided for people in their own rooms, this did not happen during the inspection. Staff carried out regular checks on people, but some of the interactions were task based and they assisted people with their care and support with little or no communication. In contrast, other people commented on how kind and caring some of the staff were.

People raised concerns about staff deployment in the home and we observed times when there were no staff in certain areas. Not everyone was able to use a call bell to summon assistance in these areas. The provider had recognised that the layout of the current building presented certain challenges, and they had a long-term plan to address this. In the interim the provider assured us that a senior staff member would make regular checks around the building to ensure staff were visible and people’s needs met.

The provider checked to make sure staff were safe to work at the service, but the checks being made did not always fully meet the legal requirements. This meant the provider’s recruitment checks were not robust enough to ensure people’s safety and wellbeing.

People’s privacy and dignity was not always upheld. Bedroom doors were routinely left open, meaning that people could be viewed easily by other people and visitors. Sometimes the people inside were asleep or not fully dressed. At times staff also failed to announce themselves when they entered people’s rooms and did not explain why they were there.

Some good attempts had been made to ensure some people’s communication needs were understood and met, but improvements were needed to explore everyone’s preferred communication methods.

The provider checked to make sure people received good quality, safe care and support. However, the auditing systems in place needed strengthening to ensure all legal requirements were met and to drive continuous improvement.

Staff ensured people received their medicines when they needed them. Risks to people were assessed too, to ensure their safety and protect them from harm, including the risk of infection. Staff understood how to report concerns and who to report to.

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. Staff asked people for their consent and involved them in planning their care and support. People were given the opportunity to make suggestions and provide feedback about the service provided to them. People’s concerns were listed to and acted on.

Staff supported people to stay healthy. Staff ensured people had a choice of food and had enough to eat and drink. They helped people to access healthcare services when they needed to and supported them at the end of their life to have a comfortable and dignified death.

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 25 May 2017).

The overall rating for the service has changed from Good to Requires Improvement. This is based on the findings at this inspection. This is the fourth time since 2015 that the service has been rated requires improvement, although not all following consecutive inspections.

Why we inspected

The inspection was prompted in part due to allegations of poor care practice and abuse involving one person living at the service. This incident is subject to a criminal investigation. As a result, this inspection did not examine the circumstances of the incident. However, we did focus on checking the safety and wellbeing of other people living at the service during the inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, caring, responsive and well-led sections of the full report. We have identified breaches in relation to staff recruitment checks and the checks the provider makes in order to assess the quality and safety of the service.

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

The provider responded immediately after the inspection by telling us they had arranged for all staff files to be checked for gaps, to ensure they contained all the required checks. They also planned to review their auditing tools.

Follow up

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The Willows is a residential care home providing a service for up to 32 adults, who may have a range of care needs, including dementia and physical disabilities. There were 29 people living at the service on the day of the inspection, and two people were in hospital.

A registered manager was in post. 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.

We found some areas that required improvement:

There were sufficient numbers of suitable staff to keep people safe and meet their needs; however, people told us they were sometimes left waiting when they called for assistance. The registered manager had already made changes to the way staff were deployed in the home and new staff had been employed. It was therefore hoped that this would improve as the new staff gained confidence and experience. Further action was taken by the provider after the inspection to enable the management team to monitor staff response times in future, to ensure people’s needs were met in a timely manner.

The provider carried out checks on new staff to make sure they were suitable and safe to work at the service. The majority of the required checks were in place however, we found some checks had not been carried out for all staff, such as obtaining a full employment history. The registered manager confirmed after the inspection that changes would be made to the existing recruitment process, to ensure all required checks were obtained in future.

Systems were in place to ensure people’s daily medicines were managed in a safe way, but these had not been followed consistently on the day of the inspection. Although no one experienced any adverse effects, the registered manager again took swift action to address our findings and confirmed that changes had been made to minimise the risk of medication errors. He also advised that a new electronic medication system was being introduced, which would improve the safe management of medicines in the future.

We also identified many areas during the inspection where the service was doing well:

Staff had been trained to recognise signs of potential abuse and keep people safe. People felt safe living at the service and staff were confident about reporting any concerns they might have. Processes were in place to manage identifiable risks within the service to ensure people were supported safely and did not have their freedom unnecessarily restricted.

Staff received the right training to ensure they had the necessary skills and knowledge to meet people’s needs.

Systems were in place to ensure the service worked to the Mental Capacity Act 2005 key principles, which state that a person's capacity should always be assumed, and assessments of capacity must be undertaken where it is believed that a person cannot make decisions about their own care and support.

People had a choice of food, and had enough to eat and drink. Assistance was provided to those who needed help with eating and drinking, in a discreet and helpful manner. Further improvements were planned in this area with the appointment of a new head chef.

The service worked with external healthcare professionals, to ensure effective arrangements were in place to meet people’s healthcare needs.

Staff provided care and support in a caring and meaningful way. They treated people with kindness and compassion and respected their privacy and dignity at all times. Personalised care plans had been developed to record how people wanted to receive their care and support, and they were supported to have choice and control of their lives as far as possible. Further improvements were planned in this area with the introduction of a new electronic care planning system.

People were given opportunities to participate in meaningful activities and further improvements were planned in this area with the appointment of a second activity coordinator, to support the provision of activities over seven days a week.

Arrangements were in place for people to raise any concerns or complaints they might have about the service. These were used by the service as an opportunity for learning and improvement. We saw that people were given regular opportunities to express their views on the service they received and to be actively involved in making decisions about their care and support.

The new registered manager provided effective leadership at the service, and promoted a positive culture that was open and transparent. Everyone felt he was approachable and fair.

Systems were in place to monitor the quality of the service provided and drive continuous improvement.

We carried out an unannounced comprehensive inspection of this service on 21 January 2016, and found that five legal requirements had been breached.

The provider sent us an action plan after the January inspection, setting out what they would do to meet legal requirements and address these concerns. We undertook this focused inspection to check that they had followed their plan and to confirm that they now met the legal requirements.

This report only covers our findings in relation to these areas. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘The Willows Residential and Nursing Home’ on our website at www.cqc.org.uk.

During this inspection on 4 May 2016, we found that improvements had been made in all areas.

The home did not have a registered manager however; a new manager was in post. The new manager confirmed she had begun the process to register with the Care Quality Commission (CQC). Like registered providers, registered managers 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.

Record keeping had improved which showed identified risks to people were now being managed appropriately.

Due to successful recruitment of new staff, the use of agency staff had decreased. There were also further plans to improve the efficiency of staffing within the home.

Safe systems were in place to ensure people’s medicines were managed in a safe way.

People were supported to have sufficient to eat and drink and this was provided in a way that met their individual assessed needs.

People’s privacy and dignity was respected and promoted.

Changes had taken place to improve the leadership, management and governance of the home.

People and staff were more actively involved in giving feedback and developing the service.

New systems had been introduced to monitor the quality of care provided to people living in the home.

Steps had also been taken to address areas identified previously as requiring improvement, such as the provision of meaningful activities for people, including those living with dementia.

Although we found that the service was no longer in breach of legal requirements, we have not changed the overall rating for the service on this occasion, because to do this this would require consistent good practice over a sustained period of time. We therefore plan to check these areas again during our next planned comprehensive inspection.

We carried out an unannounced comprehensive inspection of this service on 29 January 2015 and found legal requirements had been breached in a number of areas such as staffing, staff training, complaints, meaningful activities and the leadership of the home. However, the provider was able to demonstrate that they had identified these issues before our inspection and showed us that they had appropriate plans in place to address them. Therefore, we did not impose any enforcement actions on the provider at that time. During this inspection, we found that improvements had been made in some of these areas, but not all. Furthermore, new concerns were identified.

Shortly before the inspection we were informed that the registered manager was due to leave and a new manager had been appointed. The new manager had not yet applied to register, but told us they planned to do so. 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.

This inspection took place on 21 January 2016 and was unannounced.

We found that processes in place to manage individual risks were not sufficiently robust.

Arrangements to ensure sufficient numbers of suitably qualified, competent, skilled and experienced staff; in order to be able to meet people’s needs, were not adequate.

Systems were in place to ensure people’s daily medicines were managed in a safe way and that they got their medication when they needed it. However, these were not consistently followed.

Staff received training to carry out their roles and responsibilities, but because of a high turnover in staff, there were some gaps in training.

There were inconsistencies in the way people’s nutritional needs and preferences were being met.

People were supported to maintain good health and have access to relevant healthcare services, but they did not feel adequately involved in decisions about their own healthcare.

People were not consistently treated with dignity and respect.

The staff were mostly kind and caring, but there were missed opportunities for meaningful engagement with people.

People did not receive personalised care that was responsive to their needs.

People’s social needs were not adequately provided for, and meaningful activities were not in place for people living with dementia.

There were ineffective management and leadership arrangements in place.

The systems in place to monitor the quality of the service provided and drive continuous improvement were not always effective.

We found improvements with the maintenance of staff training records. There was evidence that staff had been trained to recognise signs of potential abuse and keep people safe.

The provider carried out recruitment checks on new staff to make sure they were suitable to work at the service.

The service worked to the Mental Capacity Act 2005 key principles.

Systems were in place for people to raise concerns or make a complaint if they needed to do so. We noted that records relating to complaints had improved and provided a clear audit trail of any actions taken in response.

You can see what action we told the provider to take at the back of the full version of the report.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who used the service, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read our full report.

Is the service safe?

Overall, our findings showed that people’s care and support was planned and delivered in line with their individual needs.

People who used the service were safe, and had their health and welfare needs met because there was enough skilled and experienced staff to meet their needs.

We spent the majority of the inspection observing the care and support provided to people who lived in the home. We walked around the home on several occasions so that our observations could take into account those people being cared for in bed. We found that people’s needs were met in a timely way, with lots of positive interactions seen between staff and people who lived in the home.

Is the service effective?

People’s health and care needs had been assessed prior to them using the service.

Before people received any care or support they were asked for their consent and the provider acted in accordance with their wishes. Although some people did not communicate using words, we observed that they were able to demonstrate their consent clearly through other methods, such as actions and physical movement. People were encouraged to make their own choices and decisions, as far as possible, throughout our inspection.

Through the course of the day we observed food and drink being regularly provided to people who lived in the home. The home’s routines were flexible and showed that people’s individual preferences mattered. One person we spoke with confirmed, “We can eat when we want.”

People were consistently asked what they wanted to eat and some were given visual choices to point to, if they were not able to communicate their choices verbally. We noted too that people were encouraged to maintain their independence as far as they were able. All the food we saw being served to people looked and smelt appetising. Assistance was provided to those who required it in a discreet and helpful manner. We heard staff explaining what they were offering to people, before putting food or drink to their mouth, and they checked to make sure people liked it before offering another spoonful.

Is the service caring?

Everyone we observed looked well cared for. We noted that staff carried out regular checks on people being cared for in bed, in order to assist them with personal care, eating and drinking, as required.

It was clear from our observations and from speaking with staff that staff had a good understanding of people’s care and support needs. We observed staff displaying genuine warmth and friendliness towards people.

Is the service responsive?

Arrangements were in place to support people who were at risk, for example because of limited mobility or poor nutritional intake. There was evidence that people’s health care conditions were regularly monitored. Where needed, support had been sought from external professionals; to ensure people's welfare was protected and all their needs met. We noted in one person’s records that their health had improved as a result.

One person was observed standing up and their dignity was compromised because their clothes did not fit adequately. Staff were quick to act and took immediate action to go out and purchase a belt to make sure the person was not at risk of falling and their dignity was protected at all times.

Is the service well-led?

The registered manager had contacted us before the inspection to advise that she was no longer working at the home. The operations manager confirmed that a new manager had been appointed but would not start until the middle of June. However, arrangements had been made for senior management presence to continue until her arrival. We learnt that the previous registered manager was still working for the same provider but in a different home. She was therefore on hand to provide information and advice to this home.

It was clear from speaking with staff that they were clear about their roles and responsibilities.

We found that appropriate systems were in place to monitor the quality of service provision and to give people the opportunity to express their views. We noted that the service was responsive to recommendations made by relevant stakeholders, such as the local authority and relatives. We saw that feedback was followed up on and recommended actions carried out in a timely way.

People told us they were happy living in The Willows Residential and Nursing Home. We observed staff offering people choices and treating them with respect and dignity. We saw that staff understood how to meet people's needs, including those with dementia.

The relative we spoke with told us they thought their relative was well cared for and spoke positively about the manager and staff team. They said they had no concerns about the care being provided by the home.

We found that systems were in place to ensure people had their medicines at the times they needed them and in a safe way.

We saw that people were safe because their health and welfare needs were being met by staff who were properly trained and supported to provide care and treatment.

Arrangements were also in place to ensure people had their comments and complaints listened to and acted on effectively.

We used different methods, such as observations, to help us understand peoples' experiences. This was because some people had complex needs which meant that they were not able to tell us about their experiences. We observed a relaxed atmosphere in the home with positive interactions between staff and people who were engaged in activities of their choice. Staff were friendly and polite in their approach and interacted effectively with people. This showed that staff understood the needs of the people they were supporting.

During our visit, we spoke with two members of staff who told us they were happy working at the home and felt supported to carry out their roles, receiving a robust programme of training and supervision.

People told us that the home was clean and we noted that the home had effective infection control processes.