The Willows Nursing Home

The Willows is a nursing home providing personal care and accommodation for up to 48 people across 2 floors. Each floor has its own communal areas. The service supports people with general nursing needs on the ground floor and people living with Dementia on the first floor. At the time of our inspection there were 38 people using the service.

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

Improvements were still being made to develop effective systems to monitor the care provided to people and to ensure people’s records reflected their needs. These systems were being reviewed and amended but needed further time to be embedded to help drive improvements in the home. The registered manager demonstrated a commitment to delivering improvements and had an improvement plan in place which was updated to include the feedback we shared during and following our inspection.

Systems were in place to review incident and accidents, and action was taken to learn lessons from these. This included a recent incident where action has been taken to reduce the risks of this event happening again. Improvements were made during the inspection to increase staffing at peak times during the day to ensure people received the support they needed.

People were supported by staff who had been recruited safely received training and understood how to protect people from abuse. People received their medicines when they needed them. People had access to healthcare professionals to ensure their healthcare needs were monitored and met.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People and those important to them, were involved in planning their care and were supported to provide feedback about the way the service was managed. People and their loved ones were happy with the service provided and felt able to approach staff and the registered manager.

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 April 2019.) and there were 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 the provider remained in breach of regulations.

The service remains rated requires improvement. This service has been rated requires improvement for the last 3 consecutive inspections.

Why we inspected

This inspection was prompted by a review of the information we held about this service. It was also prompted in part due to concerns following an incident where a person had developed sore skin. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We found no evidence during this inspection that people were at risk of harm from this concern. The provider had taken action to mitigate the risks, and this had been effective.

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 remains requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, and well led sections of this full report.

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

Enforcement

We have identified a breach in relation to the overall governance of the service. 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 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.

The Willows is a nursing home that provides personal and nursing care for up to 48 older people some who maybe living with dementia. At the time of the inspection 45 people were living at the service.

People’s experience of using this service:

People told us they felt safe: however, we found potential risks to people’s health and welfare had not always been assessed and detailed guidance was not available for staff to refer to. Not all staff had received sufficient training to deliver effective care. Although there were sufficient numbers of staff the deployment of staff required improvement. Safe recruitment processes were in place. Staff had access to equipment and clothing that protected people from cross infection.

Although people received their medicines as prescribed; improvements were required in the storage and disposal of medicines. Systems to monitor on line medicine training required improvement.

People’s needs were not always adequately assessed. Food choices were limited. Staff sought people’s consent before providing care. People’s health needs were met and people had access to healthcare services.

People’s dignity was not always respected. People’s choices and preferences were not always met because staff were often focussed on tasks. People’s independence was promoted. People and their relatives knew how to complain about the service and felt confident their concerns would be addressed.

People, their relatives and staff found the management team open and approachable. Although the audits completed had not always identified the shortfalls found at the inspection; the registered manager had begun to implement new systems to assess, identify and improve the quality of service people received.

More information is in the detailed findings below.

Rating at last inspection:

Rated Requires Improvement overall (report published 19 December 2017).

Why we inspected:

This was a planned inspection based on the rating at the last inspection. At this inspection we found the rating remained as required improvement.

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.

We last inspected this service in November 2016 when we rated the service ‘Good’ overall. We identified however that staff did not always respond promptly to people’s care needs and records did not confirm how much a person was required to drink in order to stay hydrated. This put people at risk of harm. We found the provider had taken action to address these issues.

There was no registered manager in place during our inspection visit. The registered manager had deregistered in September 2016 and a new manager who was intending to apply to become the registered manager left the service in September 2017. We were however accompanied during our inspection visit by the acting manager who was also a registered manager from another of the provider’s locations. 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. Failure to ensure a registered manager was in place is a breach of Regulation 5, Care Quality Commission (Registration) Regulations 2009. You can see what action we have asked the provider to take at the back of the report. A breach of regulation limits the highest overall rating the service can be awarded to ‘Requires Improvement’.

Staff we spoke with knew how to keep people safe from the risks associated with their specific conditions however people were not always supported in line with their care plans. Appropriate checks had been carried out to ensure people were supported by suitable staff.

People received their medicines as prescribed however further improvement was required to ensure people’s thickening powder and creams were managed safely. People told us that they felt safe in the home and staff demonstrated that they were aware of signs which may indicate that someone was being abused and the action to take.

Prior to our inspection visit we received information that people were being supported by a high number of inconsistent agency staff who did not know their care needs. We found however the acting manager had taken action so people were supported by consistent staff who had the skills and knowledge to meet their needs. Staff asked people’s opinions and respected their wishes. Assessments were undertaken when people were felt to lack mental capacity to make decisions about their care which were in their best interests. Protocols had been introduced since our last inspection to assess and protect people who were at risk of malnutrition and dehydration. People were supported with accessing other professionals to meet their needs such as a GP or optician.

People told us that the staff were caring. Staff spoke fondly about the people who used the service and how they enjoyed supporting them to engage in things they liked. People were supported to express their views about the care they received. People were able to develop and maintain social relationships that were important to them. People were supported by staff who respected their privacy.

People were supported to follow their interests and hobbies and had regular reviews with staff about how they wanted to be supported. Care records had recently been reviewed and updated so they reflected how each person wished to receive their care and support. People were encouraged to express their views of the service and assured that the acting manager would respond to concerns raised.

Prior to our inspection we had received concerns that the manager had not been effective in retaining and developing staff or monitoring the quality of the service. We found the manager no longer worked at the service and the acting manager was taking action to address these concerns. People and staff were pleased with the leadership of the home and told us it had improved. The acting manager had taken action to improve the quality monitoring of the service and also reviewed incidences to identify any trends which may affect the quality of the service. The provider did not conduct their own audits or checks of the service to identify if actions taken by the manager and acting manager were effective or if the quality of the service was at risk.

The Willows is a nursing home providing accommodation and personal care for up to 48 older people. At the time of our inspection 41 people lived at the home.

As part of its conditions of registration, this provider is required to have 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. There was no registered manager in place as they had left the providers employment in June 2016. The provider had made arrangements to make sure there was a management structure in place by way of an interim manager pending recruitment of a manager.

At our previous inspection improvements were required to staffing arrangements to make sure people’s needs were met in a timely way. At this inspection the interim manager had assessed staffing levels and was increasing staffing levels to ensure people’s wellbeing and safety were consistently met in a timely manner. However changes in staffing arrangements were in their infancy at the time of this inspection and needed time to be embedded into practice and assessed for their effectiveness.

Staff were aware of how to reduce risks to people’s safety. We saw they used specialist equipment to ensure people’s needs were met and the risks of injuries were reduced. The information for staff to follow when monitoring people’s needs required strengthening. This was to make sure staff had sufficient information to guide their daily practices when supporting people to consistently reduce risks to their wellbeing.

People were supported by staff who knew how to recognise and report any concerns so people were kept safe from harm. People were helped to take their medicines by staff who knew how to manage these in line with safe principles of practice and were continually supported by the interim manager who regularly sampled medicine administration records.

Staff were appropriately recruited to ensure they were suitable to work with people who lived at the home. They were receiving on-going training and support to deliver a good quality of care to people and more practical style of training was being organised as staff felt this would enhance their learning experiences further.

Staff respected people's rights to make their own decisions and choices about their care and treatment. People's permission was sought by staff before they helped them with anything. Staff made sure people understood what was being said to them by using a range of communication methods. These included gestures, short phrases or words. When people did not have the capacity to make their own specific decisions these were made in their best interests by people who knew them well and were authorised to do this.

Staff met people's care and support needs in the least restrictive way. Where it was felt people received care and support to keep them safe and well which may be restricting their liberty applications had been made to the local authority for authorisation purposes. These actions alongside the interim manager’s improvements in having an organised system in relation to DoLS made sure people's liberty was not being unlawfully restricted.

Staff had been supported to assist people in the right way which included helping people to eat and drink enough to stay healthy and well. People had been assessed for any risks associated with eating and drinking and care plans had been created and were being updated for those people who were identified as being at risk. People were supported to access health and social care services to maintain and promote their health and well-being.

Staff cared for people in a kind and friendly way. Staff promoted what people could do and supported people with dignity when they needed assistance. People's right to private space and time to be alone and with their relatives was accepted and respected.

Staff delivered the care which had been planned to meet people’s needs and had a high degree of knowledge about their individual choices, decisions and preferences. Staff offered people the opportunity to do things for fun and interest. There were arrangements in place for receiving and resolving complaints which took into account people's individual needs.

The views of people who lived at the home, relatives and staff were sought using different ways to develop the service and quality checks focused upon continuous improvement. The interim manager was aware of their role and responsibilities. They used their knowledge to progress improvements and was aware improvements made needed to be tested for their effectiveness and sustained so people’s experiences of care was further enhanced in the longer term.

There were nine people living at the home which was registered to provide nursing care. All of the people living at home had been assessed as requiring residential care, with no nursing requirements. The local authority had temporarily stopped new placements of people to the home.

We involve people in our inspections that have experience of social care services; we call them experts by experience. With the expert by experience we spoke to the provider, the manager (who had been in post for one week), two staff members, five people who used the service and two visitors.

We saw that people had care plans and risk assessment in place these gave staff the necessary information to deliver care. People living at the home had the opportunity to be involved in their care delivery. One person told us, 'Staff let me do what I can for myself, they are lovely people'. Staff had received training appropriate to their role this included safeguarding vulnerable adults.

Systems were being further developed to monitor the quality of the service provided at The Willows.

We had received concerns about the service provided at the home. These concerns had been raised by the local authority following an infection control audit and quality monitoring visits. At the time of our visit the local authority had stopped new placements of people in this home.

In this report the name of a registered manager appears. They were not managing this service at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time. The provider told us that recruitment to the manager post was underway.

We observed that staff were courteous and polite and treated people with dignity and respect. The staff we spoke with were knowledgeable about the care requirements for people. Plans of care for people were available and the information was reviewed monthly.

We asked staff about their understanding of safeguarding (protecting vulnerable adults). The staff gave examples of abuse and told us they were confident to report concerns to a senior staff member. There had been omissions reporting to external agencies.

Staff working within the home did not have regular one to one meetings or appraisals.

There was no process in place for the provider to monitor the quality of the service at the home.