The Willows

Updated 19 May 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was undertaken by 3 inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

The Willows is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. The Willows is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 12 people who used the service and four relatives. We observed the care and support provided and staff interactions in the shared areas.

We spoke with 12 staff members including the registered manager, senior, care, activities, housekeeping and catering staff. We also spoke with 2 visiting health professionals.

We reviewed a range of records both in the service and remotely, which the registered manager had sent us securely. Records reviewed included 3 staff recruitment files, 5 people’s care records and multiple medicines records and records relating to governance including audits and falls analysis.

We fed back out findings of the inspection via an electronic video call on 15 May 2023 to the registered manager, operations manager and 2 deputy managers.

Updated 19 May 2023

About the service

The Willows is a residential care home providing accommodation and personal care to up to 66 people. The service provides support to older people and people living with dementia. At the time of our inspection there were 49 people using the service. The service is one adapted building over three floors. At the time of our inspection, the second floor was not in use.

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

Since our last inspection, there was now a registered manager in post. The registered manager and management team had systems to continuously assess and monitor the service provided. Where shortfalls were identified, actions were taken to address them. The registered manager was committed to provide a good quality service to people and discussions with the registered manager and records showed lessons were learned and used to drive improvement when things went wrong.

There were systems in place which reduced the risks of abuse and avoidable harm. Medicines were managed safely and regular monitoring reduced risks to people. There were enough staff to meet people’s needs and staff were recruited safely. The service was visibly clean. People were supported to have visits from their family and friends.

We received positive feedback from visitors to the service. A visiting professional told us, “I am very impressed, all the bathrooms are nice and clean, staff are extortionately friendly, the atmosphere is smashing.” A relative said, “We have been surprised how good it is here, [staff] are confident in what they are doing, and we are happy [family member] is here, it feels like a community.”

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

The last rating for this service was good (published 24 September 2022).

The overall rating was good and rated good in all key questions, with the exception of well-led which was rated requires improvement, because management had been inconsistent and there was not a registered manager at the time of our inspection.

At our last inspection we recommended that the provider continued to keep the staffing levels under review and amend them, for example, when people’s needs change or increased support was needed and to ensure staff were appropriately deployed to reduce risks to people in shared areas. At this inspection we found the provider had acted on our recommendation and had made improvements.

Why we inspected

The inspection was prompted in part due to concerns received about the safety of care provided and medicines. A decision was made for us to inspect and examine those risks. In addition, we raised part of the concerns with the local authority safeguarding team, who are responsible for investigating abuse.

As a result, we undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe and well-led sections of this full report. The overall rating for the service has remained good based on the findings of this inspection. We also found the key question well-led had improved to good.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.