The Willows

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question requires improvement. At this inspection the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety.

During this inspection, we identified some fire safety concerns. For example, a cupboard used to store combustible materials had a door that did not fully close into the rebate. The door handle had been removed, and this had left 2 holes in the door. This created a fire risk and demonstrated lessons had not been learnt following previous inspections, as the provider continued to fail to identify and act on fire safety risks within the environment.

Staff told us about the changes made since the last inspection where we had found improvements were required. Comments, from staff included, “The manager talks to us and works with us,” and “We keep learning. Staff confidence has improved; records have improved, we keep giving it our best, 100%.”

The registered manager understood their responsibility to be open with people and their relatives when errors or omissions had occurred.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People’s needs were assessed before they moved into the home. This information was used to develop care plans and risk assessments to ensure staff had the information needed to provide personalised care. One staff member told us, “We talk to the family to learn about how the person wants things to be done.”

Staff worked closely with health and social care professionals to ensure people achieved good outcomes.

Staff received a handover at the start of each shift to ensure they were informed about changes in people’s needs and any planned appointments. One staff member said, “At handover your told how to care for the person if anything has changed."

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Most people felt safe from abuse at The Willows. Comments included, “I’m quite safe, there’s nothing here to make me feel unsafe,” and “No-one can get in here, it’s very safe.” However, 1 person told us, “It's not really safe, I have to lock my room at night, as 2 people keep coming into my room.” Some people living with dementia were known to walk around the home and unintentionally enter people’s bedrooms which was being monitored by the registered manager.

Staff had received safeguarding training and understood their responsibilities to keep people safe. One staff member told us, “I look for out for signs of abuse, physical, mental etc. If I had any concerns, I would report it to the manager or director if I needed to.”

Records showed the registered manager had referred safeguarding incidents to the Local Authority (LA) and Care Quality Commission (CQC) appropriately.

The provider did not work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks associated with people’s care needs were not always identified, assessed and mitigated. For example, 1 person was at risk of potential injury due to them hitting out at the wall, while lying in bed. We found no risk assessment or guidance in place for staff in relation to managing the risk of this behaviour.

People’s risk of injury from falling out of bed were not consistently mitigated or managed. Some people had ineffective mats in place, which were too short in length and offered no protection to the person’s head or lower body. Some people had thick, gym-style mats which increased the risk of falls as they presented a trip hazard. We shared our concerns with the registered manager, and they took action to mitigate the risks we had identified.

In contrast, other care records informed staff about risks associated with people’s health and wellbeing and the action they needed to take to mitigate identified risks. For example, 1 person’s care records included recommendations made by a health care professional to mitigate the risk of developing breakdown to their skin. Records confirmed staff had followed this instruction.

The provider did not always detect potential risks or take timely action to control known risks in the home.

During our inspection, we saw a cupboard used to store combustible materials had a door which did not secure fully into the rebate. This door had also had its handle removed, leaving 2 holes. The fire safety risk this created had not been identified.

A portable, free-standing radiator was seen in use in a person’s bedroom. This was plugged into an extension lead, which created a trip hazard. The bedroom was also very cluttered, with combustible materials which increased the fire safety risk. A generic risk assessment was in place; however, at the time of our inspection no evidence was available to demonstrate staff had completed the risk mitigation actions in line with this risk assessment. In response to our concerns the registered manager took action to address these safety concerns.

Whilst staff had completed fire safety training and took part in regular fire drills, they did not consistently take all the actions required to ensure people’s safety in the event of a fire or other emergency. For example, staff had not ensured information about the number of people living in the home was kept updated on a daily basis. This meant they would not have immediate access to the correct information to handover to, for example, the fire service.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development.

Most people were happy with the support they received from staff. One person said, “The staff are competent, quite polite really.” Another person told us, “Generally I see the same staff, I have a laugh with them.”

Rotas demonstrated staffing levels were maintained and people were supported by a consistent staff team. One staff member told us, “We have bank staff. If someone calls in sick, management will send someone to cover.” Another staff member said, “There is always a senior on call. We have 24-hour support.”

Staff had been recruited safely in line with the provider’s policy and best practice guidance.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

We found poor standards of cleanliness in the kitchen which posed risks of cross contamination and potential illness to people living at the home. A build-up of dirt and food debris was evident. Kitchen equipment such as the warming cabinet (used to store hot food) and the microwave were dirty and in need of a deep clean. Equipment used to reduce the risk of flies in the kitchen was broken.

The provider’s latest checks and audits on kitchen cleanliness were ineffective and had failed to identify the issues we found.

Other equipment in the home had not been replaced when needed. For example, a pedal bin lid, in the laundry room was missing. This bin had continued to be used to dispose of used personal protective equipment (PPE) and bags used for high-risk cross infection laundry items.

Whilst staff had completed infection prevention and control training and used PPE when needed. One staff member told us, “I change my PPE after every incidence. I put it on in the room and when I have finished assisting the person, I take it off before I leave the room.” They did not always ensure cross infection risks were escalated to the management team when needed.

The provider did not always make sure that medicines were securely stored. Treatments were safe and met people’s needs, capacities and preferences. Staff had been trained in the safe administration of medicines.

People’s medicines, including those requiring stricter controls were not safely and securely stored. At the start of our inspection, we found the medicine room was unlocked. The medicine keys had been left on top of the medicine trolley and the key to the controlled drug cupboard were in the keyhole. Controlled drugs are those which legally require stricter controls. This created the risk unauthorised people could access medicines. When we alerted the registered manager to our findings, they took immediate corrective action.

People received their medicines as prescribed. One person told us, “I take lots of medicines, no problem there.”

People’s medicines were administered and disposed of safely in line with the providers procedure and best practice guidance.

Staff had completed medicines training, and their competency was regularly assessed.

Weekly and monthly checks had been completed. However, audits had not identified some of the issues we found. For example, medicine stock for 1 person had not been carried forward to the current medicines administration record.