The Willows

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• 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

We found multiple breaches of the regulations and found evidence the service did not provide adequate staffing levels to ensure care was carried out in a safe and effective way. There was a shortage of staff which had impacted on the care that staff were able to offer to ensure people's needs were met. Satisfactory pre-employment checks were not always completed when staff were recruited to work in the home. This meant the provider could not be assured they were suitable to work with vulnerable people. This was a breach of regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Risks relating to people's care were not always sufficiently detailed or managed and the system for assessing risk was not robust. This was a breach of a breach of regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People were not being safeguarded from abuse and avoidable harm. This was a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Despite concerns being raised about the staffing levels, the provider had not taken swift action to ensure people were provided with care and support from enough staff working in the service. People told us they often had to wait for staff assistance when requested. Some people told us they had raised concerns with the management relating to the food provision, despite this the provider had failed to learn lessons and make improvements swiftly. Some people told us that some staff did not know how to support them in the way they needed and preferred. There were gaps in training records which evidenced that staff were not always undertaking the learning opportunities to ensure people’s needs were being met.

Some staff told us they did not feel their concerns were listened to by the management team. There was a lack of processes for staff to provide feedback about their experiences at work and share concerns about the people living in the service, such as one to one supervision meetings, to ensure views could be heard, acted on and learned from. The registered manager told us they operated an ‘open door’ where staff could speak with them about concerns. However, this was not the experience of some staff working in the service.

We were not assured the service had systems in place to learn lessons, this included in relation to staffing levels, we had previously noted 2 previous breaches of regulation in 2020 and 2021. The service had not sustained and fully embedded improvements. We asked for accident and incident analysis, including falls, for the previous 2 months. We were provided with the incident and accident analysis record for February 2024 only, which was partially completed. We noted from the records that although the records contained details of the person, there was no indication in the records of actions taken to reduce future incidents to keep people safe and reduce the risk of harm. For example, in the February 2024 document it stated, “Increase in falls on middle floor – all staff aware of those with increased falls risk,” there was no specific information of how staff had been made aware and what actions had been taken to reduce them. In addition, documentation in place to identify any safeguarding concerns received, did also not include actions taken to show lessons were learned, other than providing requested information to the safeguarding team. This was a missed opportunity to reduce risks of a reoccurrence of the concern.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We saw numerous people’s bedrooms had mesh gates across the doors. On the middle floor where mostly people living with dementia were accommodated, many people had these gates. We were told by the registered manager these were in place to safeguard people from others who entered people’s bedrooms, however, people told us this did not make them feel safer. These gates could be opened by turning a button and lifting the gate from the hook. Two people told us that other people living at The Willows were able to open the gates and enter their bedrooms uninvited. During our visit we saw 2 different males attempt to enter 2 female’s bedrooms, which made them shout out and tell them to get away. A person told us, “I choose to have the gate, some people try to get in and pick my things up. I feel safe with it, they try to open it and I shout shut the bleeding gate.” A relative said, “[Family member] had someone come into [their] room at night and it really worried [them]. The [person] just stood there. [Family member] has a gate on [their] door but at least 2 residents who wander know how to open them even if they’re locked. The carers have said they’re looking at a new gate system – I do hope so. It has really unsettled [family member].” Some people told us they felt safer having the gates in place at their bedroom door. The daily notes reviewed for people using the service, showed that on both the ground and middle floors at the care home, people had entered other people’s bedrooms, uninvited and when this was not wanted.

The management team told us they felt the service was safe and the staffing levels were sufficient to keep people safe. However, we received feedback from some staff where they were concerned about people's safety and how the staffing levels impacted on their ability to keep people safe from abuse and harm.

During our visit we saw a person kick another person, there were no staff in the communal area. We alerted staff to the incident who then attended the communal area. A staff member told another member of staff and us that these 2 people, “Are always fighting.” We asked if incidents were recorded, and they told us they were. We asked a member of the management team to tell us the number of incidents recorded between these 2 people, and there were none from January 2024 to present, they told us they knew there were behaviours where the person directed aggression to staff. The member of the management team had spoken with the staff member who told us they did not mean the incidents were physical. As part of the assessment, we asked the registered manager for the daily notes for 1 of the people, these were not received. We saw notes in a person’s daily records which raised concerns of an incident with another person which may need to be reviewed, we asked the registered manager to look into the incident, send us the incident reports and tell us what action had been taken. We had to ask for this information twice before it was received. Despite the registered manager informing us that the local authority was asked for guidance regarding if a referral should be submitted, the incident, and another also identified in the notes, was not recorded on the safeguarding log of incidents. We were not assured appropriate action was being taken when there were concerns of abuse. We shared this concern with the local authority. There was a lack of engagement provided to people to occupy them and minimise the risks of potential incidents or distress resulting in harm. There were not enough staff available to keep people safe from abuse and from distress caused by others living in the service. This was despite incidents being recorded in daily notes about the potential risks of abuse and harm.

There were gaps in the training records, which showed all staff had not undertaken safeguarding training and training in how to support people with distress and behaviours others might find challenging. Therefore, we were not assured staff were provided with the information and training they needed to recognise and act on abuse and safeguarding. We received information, which was also shared with the local authority, from visiting professionals who shared concerns about people entering other people’s bedrooms uninvited, which had caused distress and was a risk to their safety. This was in addition to further concerns raised, which were provided to the local authority safeguarding team. At the time of our assessment the local authority were also in the process of investigating safeguarding incidents at The Willows. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. Where a restriction was in place, the provider failed to demonstrate they had appropriately considered or recorded decisions for its use in line with the principles of the MCA. In addition, we had requested information from the registered manager relating to the use of the mesh gates on bedroom doors and if people’s capacity had been considered. We did not receive this information.

We were concerned people were not receiving the support they needed with their oral care. Whilst we were talking to a person, we noted they did not appear to have been supported to brush their teeth. With their permission we looked in their ensuite bathroom, there was a toothbrush in the vanity unit, which was dry, and the bristles were bent, which was an indication it needed replacing. There was another toothbrush in the same state on the sink, the toothpaste was hard to squeeze, indicating it may not have been recently used. Their care plan stated the level of support required with their oral health was high, their daily notes from 7 to 21 March 2024 showed they had been supported to clean their teeth twice.

Some staff told us they felt informed about potential risks to people’s safety and that they could find this information. We found, however, that people’s care plans and risks assessments were not consistently up to date and did not always contain essential information to keep people safe and to reduce risks.

We saw a person walking in the corridors on the ground floor, a member of the management team asked the person where their walking frame was and went to get this to provide to the person. However, we had seen this person previously walking without their frame and passed 2 staff members who did not respond to make sure the person was safe and reduce the risk of them falling.

People’s care records did not always identify how the risks on their daily living were mitigated. This included where people’s behaviours may impact on others, such as risks associated with entering people’s bedrooms. We were made aware of concerns raised to the local authority safeguarding team regarding a person who was wearing incorrect continence aides, which may have contributed to the development of pressure areas. Records showed equipment and the fire safety in the service were regularly checked. However, we noted there had not been a fire drill since October 2023. We told the registered manager what we had found. During our second visit, we saw records which showed a fire drill had been held following our first visit, which was confirmed by staff. People’s care plans held risk assessments which varied in content, with some not reflecting the person’s current needs and some not providing guidance for staff in how to mitigate risks. For example, a person took anti-coagulant medicine, there was no risk assessment or care plan in place, nor was it included in their falls risk assessment. This meant that staff were not being provided with guidance of actions to be taken to mitigate risks associated with the prescribed medicine, this placed the person at risk of harm. Records were not always consistent, a person’s dependency assessment stated they had 2 - 3 falls in the last year, but their falls risk assessment stated they had 1 fall. A person’s nutritional assessment stated there were no choking and swallowing risks, in another part of the care record it stated support required as identified by SALT to prevent choking. There were inconsistencies throughout their care plan and risk assessments which had not been fully reviewed and updated following SALT guidance in January 2024. This placed the person at risk of potential choking incidents.

We received mixed feedback about how safe people felt in living at The Willows. Some people expressed concern about other people entering their bedrooms uninvited which they told us was worrying them. A person showed us their wardrobe where one of the hinges had broken and said it was a matter of time before it fell off. They also told us they were waiting for their set of drawers to be attached to the wall, since January 2024. They told us they had reported to the manager that it had almost fell over. This placed people at risk of furniture falling them and causing them an injury.

Whilst staff did not raise any concerns about the safety of the premises and external grounds at The Willows, our assessment findings identified shortfalls as set out in this report. Since our last inspection visit, there had been changes made to the internal environment. One staff member told us how they felt the partition in the kitchenette on the middle floor was positive and minimised the risks to people accessing equipment, such as the kettle. Another staff member told us how they were undertaking checks in the service to ensure the environment was safe and well-maintained. When we checked records, however, we found gaps where the safety checks had not been completed.

We were told by some people they were worried about other people entering their bedrooms uninvited which made them feel unsafe. This affected their wellbeing and their right to feel safe in their personal space. Whilst viewing the premises we found areas of the environment that required addressing such as unpleasant odours from bathrooms an ensuites wet rooms where the flooring had limescale and water wasn’t draining fully. Since our last inspection, there had been some environmental improvements made. Air conditioning units had been installed on the middle floor corridor, where we had previously identified a concern that temperatures got very high during the summer. Due to the time of year, we visited, we could not see whether this was effective. We were also not assured how these would benefit people who remained in their bedrooms. The middle floor dining/kitchenette area had a separate work surface/cupboard installed, which prevented people to access, for example the toaster and kettle which may have posed a risk to people’s safety if using unsupervised. There was also some improvement being made through redecoration works. The registered manager told us the maintenance staff were prioritising these works since they had commenced employment working in the service.

Records showed equipment and the environment was checked to reduce risks. This included fire safety, moving and handling equipment and legionella in the water system. We found, however, that prior to the current maintenance member of staff commencing work, there were a number of gaps in maintenance records. There had also been a failure to undertake a fire safety drill to ensure staff and people knew the appropriate action to take in the event of an emergency.

Prior to our assessment, we received concerns regarding the staffing levels in the service. At that time, we were offered assurances from the management team that the staffing levels were calculated using a dependency tool and they were appropriate and safe to meet the needs of the people using the service. However, the evidence gathered at this assessment demonstrated the staffing levels were inadequate in meeting people’s identified care needs. We were not assured the staffing levels and deployment were safe to take into account the layout of the building and to meet people’s needs and keep them safe. We received mixed views from people relating to staff being available when needed and if call bells were responded to promptly. A person told us, “They were very busy yesterday, it can take a long time to get to you sometimes, I have water tablets so cannot hold myself [when they needed the toilet].” They said sometimes they had to wait over half an hour for their call bell to be answered. Another person said, “The other evening, I waited ages for the staff to come and was told they hadn’t heard the buzzer.” A relative told us, “I’ve been there when [family member] has waited at least 20 minutes.”

We raised concerns about the staffing levels with the registered manager during our first visit. In response to our feedback, the staffing levels were increased, this was only by 1 care staff member on the day shift on the middle floor at the service. The local authority also raised concerns about the staffing levels as part of a safeguarding enquiry at the service. The dependency tool in place used to calculate how many staff were required to meet people’s needs was not being used effectively and did not consider the lay out of the We raised concerns about the staffing levels with the registered manager during our first visit. In response to our feedback, the staffing levels were increased, this was only by 1 care staff member on the day shift on the middle floor at the service. The local authority also raised concerns about the staffing levels as part of a safeguarding enquiry at the service. The dependency tool in place used to calculate how many staff were required to meet people’s needs was not being used effectively and did not consider the lay out of the building and people’s individual care needs to determine the correct and safe staffing levels. There was no required date for the completion of training once a new employee commenced work. The registered manager confirmed they were in the process of improving this. The registered manager told us new staff shadowed more experienced colleagues for 2 weeks. We saw an induction checklist, which was a set of information provided to new starter. There were gaps in training records, which the registered manager told us they had identified, however following the date given for staff to complete, there were still gaps.

During our visits, we saw there were not always staff present in the communal areas of the home with people. This was important particularly where people had complex needs and needed to be supported to ensure all people in the service were safe. Staff were busy providing care to people in their bedrooms and had no time to spend with people to provide social stimulation. The catering staff prepared the evening meal, and this was served by the care staff, taking them away from their caring duties. During our visit we saw a person leaving the service with their relative. Staff told us this person received day support at The Willows and did not live in the service. They said the person was one of 2 people who attended the service for day support. The provider’s dependency tool did not consider the needs of those 2 people and the staff support required. We viewed staff recruitment records to ensure the correct and safe pre-employment checks were being undertaken prior to staff commencing work at The Willows. Staff recruitment records included checks such as the right to work in the UK and Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. One of the staff recruitment records we viewed held no references to show checks had been made on the person’s previous employment and character. We were told this would be addressed. There were no probationary meetings in place for new staff to show their performance was being monitored and any training needs they had. There were limited one to one supervision and probation meetings for staff to discuss the ways they were working and to identify any training needs. Where recent supervisions were in place, these related to specific incidents where staff were told of the requirements of their role.

The numbers of staff available to support people were not sufficient to ensure people’s care needs and preferences were met. We were not assured that dependency level assessments were always correct to assist the registered manager and provider to assess the required staffing levels in the service. For example, the dependency assessment for 1 person did not reflect their needs which were reflected in their daily notes, such as behaviours demonstrated to people using the service and staff. Another person’s dependency stated they did not display physical aggression, but elsewhere in their care plan it stated they did. This inconsistent recording meant that staff may be unaware of each persons individualised needs. We were concerned that the staffing levels were impacting on people’s wellbeing and safety, despite being reassured by the management team staffing levels were safe and people’s and preferences were being met. For example, on the top floor there was 1 senior staff member and 1 care staff member on duty during the day to support 10 people, 2 of whom needed the support of 2 staff with their personal care needs. During the morning the senior staff member supported people with their medicines, leaving the care staff member to help people get ready for the day, support people with their breakfast and keep people safe. There were not sufficient staff to support the people who required the support of 2 staff, when 1 of the staff was busy with providing people with their medicines. The registered manager told us other staff could support from the other floors; however, we were also concerned about the numbers of staff on each floor. We viewed staff recruitment records to ensure the correct and safe pre-employment checks were being undertaken prior to staff commencing work at The Willows. Staff recruitment records included checks such as the right to work in the UK and Disclosure and Barring Service (DBS) checks.

People and their relatives were mostly positive about the standards of cleanliness at the service with some citing some challenges. One person said, “They [housekeeping team] come in and clean in here and the bathroom. Sometimes though they run out of time.” Another person said, “They clean my room most days.” A relative told us they had noted their family member’s bin was not always emptied in their bedroom and gave an example of when they had thrown some flowers in the bin, which were still there the following week.

Members of the housekeeping team told us there were enough of their team to keep the service clean and hygienic and that they were provided with the equipment they needed. A staff member told us how they monitored the cleanliness in the home and how the team acted quickly to ensure any spillages and/or body fluids were cleaned promptly.

Prior to our assessment, we had received concerns about malodours in the service. During our visits we noted that there were intermittent malodours, but these were removed as staff cleaned areas. The communal areas were visibly clean; however, we found some areas in people’s bedrooms which needed attention. We saw a person’s bedside table was unclean and sticky, a person’s duvet was stained as was their wall, a person’s ensuite had a musty smell and there was a water mark in the shower area, some carpets were in need of hoovering having debris, a pair of tights and debris was identified under a person’s bed. A person’s bin in their bedroom did not have a liner in it and there was a pair of gloves in the bin, which was a risk to the person if they accessed them. A person had their bare feet on a dining room table, where people were served with meals and drinks. This posed an infection control risk.

There was a head housekeeper in post who monitored the service was clean and hygienic along with a team of housekeeping staff. The registered manager told us daily head of department meetings were held and any issues with the cleanliness of the service would be discussed, where required.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.