Willows Care Home

Willows Care Home is a residential care home providing personal and nursing care to up to 73 people. The service provides support to older people, a number of whom live with dementia. At the time of our inspection there were 40 people using the service.

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

Refurbishment improvements were required across communal areas and bedrooms. At our last inspection the provider shared ongoing refurbishment and redecoration of the home was planned and ongoing. However, at this inspection we saw limited improvements had been made and a deterioration of the management of infection control due to this.

We identified improvements were required to the staff deployment across the home to ensure staff were available to provide care to people promptly. During the inspection we observed long periods where people were left in communal lounges with no staff present to provide support promptly, which left people at risk.

We observed a lack of engagement and activities in communal areas and for people nursed or remained in bed. At our last inspection this was an area of improvement we identified the provider required to make; at this inspection a new activity co-ordinator had been recently employed. While we saw some evidence of actions taken recently, this had not been embedded to enable sustained improvement.

Medication was administered safety; however, improvements were required to ensure that medication stock is managed effectively.

Care plans required further improvements to prompt staff on actions to complete when providing bespoke care and supporting people’s welfare.

Audits and checks the provider made were inconsistent and some actions identified were not always completed. This meant people were receiving inconsistent care and there was a failure to ensure consistent effective monitoring of risk and quality of the home.

People spoke positively regarding the care they received from staff at Willows Care Home. While we received some mixed responses from relatives regarding the home, overall relatives we spoke to were positive regarding staff and care their loved ones received.

Staff spoke positively about working at Willows Care Home, acknowledging area of improvements they wished to see the provider make. Some staff spoke about the regular changes of management within Willows Care Home and the challenges this creates providing consistent care to people.

There had been recent changes to the management team since our last inspection. The manager was open and transparent to any queries of concerns we raised during the inspection.

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.

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 8 March 2023). 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 regarding the quality care for people. A decision was made for us to inspect and examine those risks and review the previous rating.

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.

Enforcement and Recommendations

We have identified repeated breaches in relation to a lack of planned activities within the home for people to participate in and inconsistent oversight of the quality of care at the service.

We identified a breach in relation to safety or premises and ability to ensure effective infection control measure are maintained due to the on-going refurbishment requirements at the home.

We have also made recommendations relating to safe deployment of staff across the home and dementia friendliness of the home in line with best practice. We also recommended the provider reviewed care plans to ensure they provide information to prompt staff in areas of care for people.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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 alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Special Measures

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.

Willows Care Home is a residential care home providing personal and nursing care to up to 73 people. The service provides support to older people, a number of whom live with dementia. At the time of our inspection there were 36 people using the service.

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

There had been changes to the management team since our last inspection. Routine audits had not fully been in place for a number of months. This meant there had been a failure to ensure effective monitoring and review of risk as well as the quality of the service provided to people. The new management team had introduced new systems to monitor quality, however these were yet to be embedded to enable sustained improvements to be demonstrated.

Staff absence and recruitment difficulties had created shortfalls in the ability to fully protect people from the risk of infection or to ensure people had access to activities which were meaningful to them. Ongoing attempts to recruit to a number of staff vacancies were underway. Appropriate checks on staff were in place to ensure they were suitable for the role before working with people.

We also identified improvements were needed to enhance peoples experience at mealtimes and to the quality of some of the training staff receive.

Although we found some improvements were needed, people did speak positively of the care they received at Willows Care Home. Significant work had been done to ensure care plans were reflective of people’s current needs. 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. Policies and systems were in place to support best practice. The communication needs of people were clearly documented, and people had access to appropriate healthcare services.

Checks were in place to ensure people lived in a safe environment. Ongoing refurbishment and redecoration of the home was planned and ongoing.

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 requires improvement (published 25 December 2021). The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

Enforcement and Recommendations

We have identified breaches in relation to a lack of planned activities within the home for people to participate in and insufficient oversight of the quality of care at the service.

We have also made recommendations the provider reviews the quality of some of the training provided to staff and the quality of the experience for people at mealtimes.

Please see the action we have told the provider to take at the end of this report.

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 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 alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Willows Care Home is a nursing home for older people and people living with dementia. The service is registered to provide personal care to up to 73 people. There were 27 people living at the service at the time of the inspection.

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

Improvements had been made to the safety of the service. COVID-19 guidance to reduce the risk of infection had been fully implemented and consistently followed. Items that placed people at risk were stored safely and securely and the service was clean and hygienic.

The governance and oversight of the service had improved. Audits identified areas that needed improvement and action plans had been developed to address shortfalls. The accuracy and level of detail of records had improved and care plans accurately reflected people's needs. The systems in place to check the completion of medication administration records (MAR) had improved and the management of medicines was safe.

Relevant identity and security checks had been completed before staff were employed and staff were deployed in sufficient numbers to meet people’s needs. Staff all reported being happy in their work and agency use to cover vacancies and unplanned leave had reduced. Staff felt the manager and management team were supportive, approachable and listened to their views.

Staff had completed training in protecting people from abuse and the manager had referred incidents of potential abuse to the local authority in line with local protocols.

People's relatives and staff felt the service was managed well and the management were approachable. Relatives told us they were kept informed of their loved one’s wellbeing and consulted with when decisions were made about their loved one's care and treatment. They also felt their loved ones were cared for by kind and caring staff who kept them safe.

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 inadequate (published 13 May 2021) and there were multiple breaches of regulation. 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 improvements had been made and the provider was no longer in breach of regulations.

This service has been in Special Measures since 30 July 2020. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This was a planned inspection based on the previous rating.

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.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from inadequate to requires improvement. 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 Willows Care home on our website at www.cqc.org.uk.

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

Willows Care Home is a nursing home for older people and people living with dementia. The service is registered to provide personal care to up to 73 people. There were 29 people living at the service at the time of the inspection.

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

On the first day of our inspection we found many risks to people's health and safety, identified at our last two inspections, had not been addressed. We also identified further issues with the environment that that placed people at risk of harm.

We found walls, floors and equipment in some bathrooms were still in a poor state of repair. Unclean items such as hairbrushes and cutlery were accessible to people and a cupboard containing items that could cause harm if ingested was left unlocked. An electrical installation inspection report of lights and sockets completed 3 February 2021 identified nine issues that needed addressing but no remedial action had been taken or planned.

We also found the provider had still not fully implemented COVID-19 guidance to reduce the risk of infection. People and staff were not consistently monitored for signs and symptoms of COVID-19 and we saw some staff were not wearing masks. Although visiting was taking place, there was no cleaning schedule for the visiting room in which we found dirty mugs. Visiting professionals were not screened for signs of COVID-19 or asked to produce evidence of a negative test and infection prevention and control policies were not reflective of current guidance.

Following our visit, we urgently raised our concerns and required an urgent action plan along with assurance from the provider that they would to address environmental safety issues and ensure national COVID-19 infection, prevention and control guidance was followed. The provider sent us an action plan and on the second day of the inspection we found this was being followed.

Aspects of the governance and oversight of the service were not robust. Audits had not always identified areas that needed improvement and action plans had not always been developed to address shortfalls. Records had not always been accurately completed, kept up to date or stored securely. The systems in place to check the completion of medication administration records (MAR) were not always effective.

Improvements had been made to the recruitment and deployment of staff. Relevant identity and security checks had been completed before staff were employed and staff were deployed in sufficient numbers to meet people’s needs. Staff morale had improved, and staff turnover had reduced. Staff felt the manager and management team were supportive, approachable and listened to their views.

Most staff had completed training in protecting people from abuse and the manager had referred incidents of potential abuse to the local authority in line with local protocols.

People's relatives told us they were kept informed of their loved ones wellbeing. They also felt their loved ones were cared for by kind and caring staff who kept them safe.

We have identified continuing breaches in relation to the management of infection prevention and control and the governance of the service.

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 inadequate (report published 10 December 2020). At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

This was a planned focused inspection based on the previous rating. It was undertaken in part to check whether the Warning Notices served at our unannounced targeted inspection on 28 October 2020 in relation to Regulation 12 and Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. We also checked they had followed their action plan to meet the breaches of legal requirements found at our focused inspection 9 July 2020. Following that inspection the provider completed an action plan to show what they would do and by when to improve staffing, recruitment, safe care and treatment and the governance of the service.

This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

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.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Willows Care Home on our website at www.cqc.org.uk.

The overall rating for the service has remained inadequate. This is based on the findings at this inspection.

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

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 six 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 of their 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.

Willows Care Home is a care home providing accommodation for up to 76 older people, including people living with dementia. At the time of the inspection there were 34 people living at the service.

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

We received information raising concerns about the management of accidents and incidents. This inspection looked specifically at these areas.

The providers quality assurance processes had not been used to monitor the service effectively and had failed to identify and improve shortfalls in relation to infection prevention and control, the management of accident and incidents, staff induction, training and support.

People were not protected from the risk of infection and not all areas of the service were clean. Staff were not all following the latest infection control guidance or wearing personal protective equipment (PPE) appropriately. The provider's infection prevention and control policies and procedures were not reflective of the COVID-19 pandemic.

Staff had not received the induction, training and support they needed to deliver safe, effective care and fulfil their role.

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

Rating at last inspection

The last rating for this service was inadequate (27 July 2020) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

Why we inspected

We undertook this targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in response to concerns received about the management of accident and incidents. A decision was made for us to inspect and examine those risks.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

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 .

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to infection prevention and control, the governance of the service and staff training and support.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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.

Willows Care Home is a nursing home for older people and people living with dementia. The service is registered to provide personal care to up to 73 people. There were 38 people living at the service at the time of the inspection.

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

The service had not been well managed. The governance and oversight of the service was insufficient to ensure people received support to keep them safe and maintain their wellbeing. Audits had not always been completed or been used to effectively drive improvements in the quality and safety of the service people received. Records had not been accurately completed, kept up to date or stored securely and staff did not feel listened to.

Risks to people's health and safety had not been consistently assessed and mitigated. The registered person(s) failed to ensure there was sufficient oversight of the care of people who had experienced unintentional weight loss or were at a high risk of falls. Medicines were not always stored safely and the competencies of some staff who administered medicines had not been assessed. Staff recruitment had not been robust, and the relevant checks had not always been completed. Staff had not been deployed in sufficient numbers to meet people’s needs. People who needed support or were at high risk of falls were not always supervised when they were in communal areas.

The service was clean and hygienic, and most staff had completed training in protecting people from abuse.

We have identified breaches in relation to the management of risks to people, staff deployment, staff training, staff recruitment and the governance of the service.

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 (report published 3 January 2020).

Why we inspected

We received concerns in relation to staffing levels, weight loss, falls and the management of the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. Following the inspection, we met with the provider who gave us some assurances and shared an action plan detailing the improvements they had already made and those they intended to make.

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 inadequate. This is based on the findings at this inspection.

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

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 six 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.

Willows Care Home is registered to provide personal and nursing care to older people and specialises in supporting people living with dementia. The service accommodates up to 73 people over three separate units. At the time of our inspection there were 68 people using the service.

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

Prior to the inspection, the previous registered manager and deputy manager had resigned from their posts. They had remained at the service to help provide consistent support until the newly recruited manager came in to post. They both remained passionate about providing person-centred care and this was evident in the observations made during inspection.

Despite the uncertainty felt by the staff team due to the management changes, people continued to receive kind, caring and compassionate care. Staff told us people came first and were keen to implement the person-centred care managers had instilled in them. People told us they felt safe and well cared for.

Risks to people had been identified and assessed with guidance in place for staff to follow to ensure people did not come to harm. Where people displayed behaviours that may challenge, regular reviews were completed to help identify triggers and create support plans to enable staff to provide effective care. Staff knew how to recognise signs of abuse and were confident reporting any concerns they may have.

People’s medicines were managed safely by trained staff and guidance was in place for people who received medicines ‘as required’. Staff used effective methods and techniques to manage situations where people became distressed which had resulted in a reduced need for some ‘as required’ medicines to be administered.

Enough suitably qualified and trained staff were deployed to meet people’s needs. Staff commented on the good teamwork they had and how they supported each other. They told us they received good training and support from the managers and registered provider.

People’s needs had been holistically assessed and plans were in place to help manage these. People had access to other health and social care professionals when needed and staff followed the guidance they provided. People were supported to maintain a healthy balanced diet and spoke positively about the food provided. Staff had good knowledge of people’s individual dietary needs and preferences and gave support during meal times when needed.

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.

The services’ activities coordinator had developed strong relationships with people and it was clear they responded positively to his interactions. Activities were regularly used as a way of managing behaviours that challenge. Staff told us these methods had helped to reduce some people’s anxieties and distress. An additional activities co-ordinator had been recruited to provide one-to-one sessions for people who preferred this.

People and family members spoke positively about the management of the service and did not feel the recent changes had affected the care they received. People were confident raising concerns. The manager’s and registered provider’s ‘open door’ policy created an environment that was relaxed and supportive. Effective systems were in place to monitor the quality and safety of the service and the registered provider was keen to improve the quality of care people received.

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 requires improvement (report published 18 December 2018)

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.

Since the previous inspection the management team and staff had worked hard to make necessary improvements to the service and the quality of care provided. The Willows had undergone some refurbishments to make the home safer and more visibly appealing. The work completed had also made the environment more meaningful for people living with dementia. The registered manager and deputy manager told us of their plans to further develop the environment to promote more positive engagement, stimulation and socialisation for people living in the home.

The atmosphere at The Willows was now calm and homely; the management team and staff had developed strong, familiar and positive relationships with people and family members. Throughout the inspection the registered manager, management team and staff were seen to be warm and affectionate towards people and often displayed physical contact that was appropriate and accepted by people.

Staff showed a genuine motivation to deliver care in a person centred way based on people’s preferences. People were treated with kindness, compassion and respect. Staff used techniques to help relax people with positive outcomes. Everyone we spoke with told us The Willows was now a more homely place to live.

People told us they felt safe living at the service and family members were confident their relatives were kept safe. Risks that people faced were identified and assessed and measures put in place to manage them and minimise the risk of harm occurring. Staff showed a good understanding of their roles and responsibilities for keeping people safe from harm. Medicines were managed safely and people received medication at the right time. The environment was safe and people had access to appropriate equipment where needed.

Enough suitably qualified and skilled staff were deployed to meet people’s individual needs. The registered manager had recently recruited new permanent staff and told they would continue to do so. On some occasions agency staff were used to cover any shortages with staffing numbers. Staff received a range training and support appropriate to their role and people's needs.

People’s needs and choices were assessed and planned for. Care plans identified intended outcomes for people and how they were to be met in a way they preferred. People told us they received all the right care and support from staff who were well trained and competent. People received the right care and support to eat and drink well and their healthcare needs were understood and met. People who were able consented to their care and support. Where people lacked capacity to make their own decisions they were made in their best interest in line with the Mental Capacity Act.

People received personalised care and support which was in line with their care plan. People, family members and others knew how to make a complaint and they were confident about complaining should they need to. They were confident that their complaint would be listened to and acted upon quickly.

The leadership of the service promoted a positive culture that was person centred and inclusive. People, family members and staff all described the registered manager and deputy manager as supportive and approachable. The management team showed a continued desire to improve on the service and worked closely with other agencies and healthcare professionals in order to do this. Effective systems were in place to check on the quality and safety of the service and improvements were made when required.

More information is in Detailed Findings below

Rating at last inspection: Inadequate (report published 15 May 2018).

About the service: Willows Care Home is situated in Blacon, Chester. The service accommodates up to 73 people over three separate units and provides nursing and personal care. Some people using the service are living with dementia. At the time of the inspection 40 people were living at the home.

Why we inspected: This was a planned inspection based on the rating at the last inspection. The service had improved from inadequate to requires improvement overall.

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

At this inspection we identified new and repeated breaches of the regulations. These were in relation to assessing and mitigating risks to people’s health and wellbeing, safe care and treatment, meeting nutritional needs, dignity and good governance.

We will update the section at the end of this report to reflect any enforcement action taken once it has concluded.

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

The care home accommodates 73 people. There are three separate units, each of which has some separate facilities such as bathrooms and sitting areas. At the time of the inspection 54 people were living at the home.

There was 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.

Quality assurance systems were in place but these had again failed to identify risks presented to the people who lived at the home. The registered provider did not address the concerns raised during this or the previous inspection. The registered provider had failed to notify the CQC of some notifiable incidents. There was insufficient analysis of accidents and incidents (such as falls) in order to learn from them and mitigate risk.

People could not be assured that risks to their safety were always fully assessed or kept under review. Risks were not always reduced as much as possible and therefore, the registered provider was not taking reasonable steps to keep people safe.

People lived in an environment which required repair and refurbishment in order to fully meet their needs. Premises were not visibly clean or free from odour. This meant that there was an increased risk of acquired infection.

People had medication as required and these were recorded and administered correctly. However, some medications such as creams and thickening agents were not stored in accordance with good practice guidance which placed people at risk of harm.

People had a mixed opinion of the meals that they received although families felt it to be sufficient. The food prepared was not always kept hot or served quickly which impaired a person’s enjoyment of their meal. Others were served puree meals when they had been assessed as able to eat a variety of soft foods. Staff did not provide adequate assistance where people required support to eat or drink sufficient amounts.

People were supported by staff that they described as were caring; however from observation we saw that people could not always be assured that they were treated with dignity and respect. We found that staff did not respond quickly to meet people’s needs and lack of adequate monitoring placed people at risk of harm.

Care plans were detailed and person centred. However, these were not always updated following any changes. The care and support of people who lived at the home did not always follow their care plan requirements. This meant that there was a risk that their needs were not fully met.

Improvements had been made to the staff induction and supervision programme since our last visit. Staff received training and supervision to provide them with the knowledge required for their roles. We made a recommendation around equipping staff with the skills to manage behaviours that challenge.

People and their representatives knew how to raise concerns and had some confidence that changes would occur. When concerns had been recorded, there was a record of what action had been taken.

Staff had an understanding of the Mental Capacity Act and its principles. There was a record of a person’s capacity to make a specific decision and where staff or others had made a decision in a person’s best interest.

Recruitment and selection processes were in place to ensure that vulnerable people were protected from receiving care from unsuitable people. Evidence was not available to show that this had been followed in every instance.

The overall rating for this service is ‘Inadequate and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

Willows Care Home is split into three units that support people with conditions associated with old age and physical disability as well as people living with dementia. The service is registered to accommodate a maximum of 73 people. At the time of the inspection there were 51 people living at the service.

The last inspection of the service took place on the 20 and 21st August 2015 and at the time the service was meeting the regulations we assessed.

There was a registered manager who was registered in September 2016. 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 that the registered provider was not meeting all of the requirements of the Health and Social Care Act 2014 and you can see what action we told the provider to take at the back of the full version of the report.

Staff supported people in a patient manner and it was evident that relationships between people and the staff that supported them had been developed. People who used the service told us that they felt safe and well cared for. Relatives were happy with the care that people received and they expressed no significant concerns. However, we observed that people were not always treated with dignity and respect. This was particularly where people were supported in bed or required assistance during meal times.

At the last inspection we made a recommendation that the registered provider improved people’s dining experience. We found that this was still variable and improvements required around support for people living with dementia. People told us that they liked the food and there was a choice of meals available. Although people received the help they required with eating and drinking, their independence was not always promoted.

Staff did not all receive an induction that met with the requirements of the care certificate framework to ensure that they had the skills and knowledge to carry out their job. Staff competency to carry out their role was not assessed before or during their period of employment. This meant that the registered provider could not be assured that they had the right skills, knowledge and values. Staff were provided with regular training but there was no system in place to assess how staff demonstrated the skills they had learn in their day to day work. Staff told us that they felt supported. However, one to one support and supervision was not provided in line with the registered providers own policy.

The environment and the building required improvement to ensure that it was clean, well maintained and met the needs of the people that lived there. The registered provider had commenced a programme of refurbishment and improvement that was planned to be completed by December 2016.

People were cared for by staff that had undergone the appropriate recruitment and selection checks to ensure that they were of suitable character for the job. Further checks were required to verify references provided.

The registered provider had a quality audit system in place to monitor the safety and effectiveness of the service. This identified both areas of concern and areas for improvement. We saw that actions were taken where concerns had been highlighted to minimise the risk of reoccurrence. The audits were not completely robust as they did not highlight all of the issues found on inspection.

The service had systems in place to ensure the safe administration and management of medication. Staff ensured that there was monitoring in place where people had specific health conditions. This meant that people received the correct treatment and support.

Activities took place and we saw evidence of this during our visit. A weekly programme was planned that gave the opportunity for games, movies, life skills and quiz like activity. This was flexible and the content depended on the wishes of the people at the service and the staff available to support

The registered provider had a safeguarding policy in place that staff were aware of. Staff were able to identify safeguarding concerns and knew how to report them. Safeguarding incidents and low level care concerns had been reported to the local authority and to the Care Quality Commission (CQC) where appropriate.

People, who were deprived of their liberty, were done so in accordance with the requirements of the Mental Capacity Act 2005. Where a person’s liberty was being restricted or they were under continuous supervision, we found that the registered manager had made the appropriate application to the supervisory body under Deprivation of Liberty Safeguards. Where a person lacked capacity to make a specific decision or choice, staff documented why decisions had been taken in somebody's best interest. This meant that the rights of people not always able to make or communicate their own decisions were protected.

People’s care and support needs were reviewed on a regular basis. Care planning documents were updated when required and appropriate referrals were made to healthcare professionals.

The registered manager had a process in place to ensure the recording of accidents, incidents and risks to people’s health and safety. Remedial action had taken place to minimise risks, for example falls.

We found that a plan was in place to refurbish all of the bathrooms at the home by end of 2013. In addition to this some bedrooms currently had new built in furniture.

We spoke with seven members of staff. They all told us they thought they had enough staff to meet the needs of the people who used the service. Two of them told us that they were always very busy but the needs of the people who lived at the home were always met on a daily basis. Staff also told us they always had the opportunity to have a meal break. Staff told us that they felt well supported and they had the information they needed for their roles. Comments from staff included; "The new manager has brought some good ideas to the table" and "I'm supported 100%. There's plenty of training opportunities."

We found there was an effective system in place to deal with complaints. It was evident there was a detailed audit trail of how concerns were managed and dealt with to the complainants satisfaction were possible.

We found that current records were kept securely and could be located promptly when needed. This included staff personnel files and clinical records for people who used the service.

The compliance manager for Willows Care Home provided us with information since our last inspection. This demonstrated they had taken appropriate action to ensure that people are protected from the risk of abuse. We saw that the provider had an effective system to regularly assess and monitor the quality of service that people receive.

"I am keeping well in my health but if I become ill-they always get a doctor to me"

"The staff are very good"

"We are looked after here"

"I feel safe living here"

"They are very friendly and helpful"

"They do keep me informed of any changes to my relation's health-they have sometime been delays in this but on the whole they tell me"

"They do look after my relative's health and I think they are safe living here"

We found that staff were responsive to the needs of people but there were instances with two staff where interactions were limited and little communication occured between the members of staff and the people they supported. The health and well being of people was maintained and regularly reviewed.

The service does not always have arrangements in place to ensure that people were protected from abuse and we found that staff did receive occasional training and supervision. There were measures in place to measure the quality of care provided yet this did not extend to the provider providing a commentary on the care provided.