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Inspection Summary

Overall summary & rating


Updated 1 June 2018

Willows 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 home has been converted from a large three storey house close the centre of Birkdale, near Southport. The home can accommodate up to 28 people with a variety of nursing needs. There were 21 people in residence at the time of the inspection.

This was an unannounced inspection and it took place on 8 and 11 May 2018.

At the last comprehensive inspection in April 2017 we found a breach of regulations with in respect to, induction and training standards for new staff and medicines management. The service was rated as ‘Requires improvement’. We followed this up in September 2017 to review the breaches of regulations we found improvements and the breaches had been met. We did not review the overall quality rating at that time and the home remained ‘Requires improvement’.

On this inspection we found improvements had been sustained and the home had continued to develop. On this inspection we rated the service as ‘Good’.

A manager was in post who was in the process of becoming registered with the Care Quality Commission. 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 manager had previous experience of working at senior level with the registered provider.

Potential risks to people using the service were clearly identified. Effective care plans had been agreed with people so that potential risks could be reduced.

Medicines were safely stored and administered in accordance with best-practice and people’s individual preferences. Nursing staff were updated and trained in administration. The records indicated that medicines were administered correctly and were subject to regular audit.

Key documentation included attention to ensuring peoples consent to any care and treatment was recorded and operated in accordance with the principles of the Mental Capacity Act 2005 (MCA).

The Willows had improved much of their key assessment and care planning documentation and it was now clear and detailed regarding peoples care. People’s needs were assessed and recorded by suitably qualified and experienced staff. Care and support were delivered in line with current legislation and best-practice.

The service had continued to develop quality monitoring processes and the manager had support from senior managers in the organisation.

Policies and procedures provided guidance to staff regarding expectations and performance. These included policies regarding equality and diversity. Staff were clear about the need to support people’s rights and needs and recognised individual needs. Care records contained information about people’s sexuality, ethnicity, gender and other protected characteristics. We discussed ways during feedback how this area could be developed further; this included attention to developing the visible cues in the environment to accommodate people living with dementia.

People using the service and staff were involved in discussions about the service and were asked to share their views. This was achieved through daily contact by the managers and staff and regular surveys and meetings. These provided very positive responses regarding people's care.

Overall the service maintained effective systems to safeguard people from abuse and the service had worked effectively with the local safeguarding team when needed.

We saw evidence that the service learned from incidents and issues identified during audits. Records showed evidence of review by senior managers.

The service ensured that

Inspection areas



Updated 1 June 2018

The service was safe.

There were systems in place to assess and monitor any risks people may present to their safety. There were protocols in place to protect people from abuse or mistreatment and staff were aware of these.

The environment was monitored to help ensure it was safe and well maintained.

Staffing numbers were satisfactorily maintained to support people. Staff had been appropriately checked when they were recruited to ensure they were suitable to work with vulnerable adults.

Medicines were administered safely.



Updated 1 June 2018

The service was effective.

Staff said they were supported through induction, appraisal and the services training programme.

The service supported people to maintain their health and wellbeing.

Staff sought consent from people before providing support. When people were unable to consent, the principles of the Mental Capacity Act 2005 were followed.

People�s dietary needs were managed with reference to individual preferences and choice.



Updated 1 June 2018

The service was caring.

When interacting with people staff showed a caring and friendly nature with appropriate interventions to support people as individuals. Staff told us they had time to spend with people and engage with them.

People told us their privacy was respected and staff were careful to ensure people�s dignity was maintained. We discussed the need to review one policy regarding providing personal care to people.

People told us they felt involved in their care and on-going reviews of care.



Updated 1 June 2018

The service was responsive.

Care plans were completed and reviewed when needed so people�s care could be monitored and adapted.

There were a range of social activities planned for people and the manager had ideas as to how these could be further improved.

A process for managing complaints was in place and people and relatives knew how to complain. Complaints made had been addressed.




Updated 1 June 2018

The service was well led.

There was a manager who was currently being registered with the Commission. There was a clear management structure with lines of accountability and staff responsibility which helped promote good service development.

There were a series of on-going audits and checks to ensure standards were being monitored effectively. These had been developed to better identify the needs of the service on-going.

The Care Quality Commission had been notified of any reportable incidents.

There was a system in place to obtain feedback from people so that the service could be further developed with respect to their needs and wishes.