The Willows

Updated 16 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.

Inspection team

The inspection was completed by 2 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. However, they had left the service prior to the inspection and a manager from one of the providers other services was providing support.

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 3 people who lived at the service and 4 relatives about their experience of the care provided. We spoke with 5 members of staff including the area manager, the manager, senior care workers and care workers.

We carried out a visual inspection of the home to assess the living environment and observed interactions between staff and people who lived at the service. We reviewed a range of records. This included 3 people's care records, and multiple medication records. We reviewed a variety of records relating to the management of the service, including audits, policies, and procedures.

Updated 16 May 2023

About the service

The Willows is a residential care home that provides accommodation and personal care for up to 39 people aged 65 and over, some of whom maybe living with dementia. At the time of this inspection 9 people were living at the service.

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

Whilst some improvements had been made in relation to the oversight and quality assurance at the service; the management team failed to ensure people were correctly safeguarded where concerns were identified. Appropriate action was not always taken in relation to allegations of abuse and the management team failed to follow their own safeguarding policy to protect people.

Infection control was not always promoted to ensure a safe environment. Areas of the service were odorous and some furniture did not support effective cleaning to take place. Safe infection prevention and control practice was not always promoted. There was a lack of clinical waste bins for staff to dispose of soiled incontinence aids and personal protective equipment was not stored appropriately.

Some improvements had been made to peoples care plans and risk assessments, however, further work was required. Records to support the monitoring of people’s health and wellbeing were not always accurately completed or provided staff with sufficient information to provide consistent care.

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 their relatives were happy with the care and support received. Relatives spoke positively about the improvements that had been made at the service. Staff were supported in their role and felt the management team was approachable.

For more details, please see the full report which is on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was inadequate (published30 November 2022).

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.

At our last inspection we recommended that the provider monitored supervision and training of staff. At this inspection we found the provider had ensured staff were trained and supported.

This service has been in Special Measures since 20 December 2021. 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 inspection was carried out to follow up on action we told the provider to take at the last inspection.

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.

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 is requires improvement.

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.

Enforcement and Recommendations

We have identified breaches in relation to safeguarding, safe care and treatment and good governance at this inspection. We have made a recommendation regarding the safe recruitment of staff.

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 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.