The Willow

About the service

The Willow is a children’s home which is registered for accommodation for people requiring personal or nursing care as well as treatment of disease, disorder or injury. The service can accommodate one person. The service provides therapeutic psychological support to children and young people with mental ill health and additional needs, such as neuro-developmental disorders. At the time of our inspection there was one person using the service.

Ofsted are the lead regulator for services registered as children’s homes, however, the service was not registered with Ofsted at the time of our inspection.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support: Model of Care and setting that maximises people’s choice, control and independence

Right Care: Care is person-centred and promotes people’s dignity, privacy and human rights

Right Culture: The ethos, values, attitudes and behaviours of leaders and care staff ensure people using services lead confident, inclusive and empowered lives.

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

The provider had not always made sure that person centred care was provided in a way that met the needs of service users, particularly in relation to their diagnosis of autism as well as nutrition and hydration.

Action had not been taken to make sure that changes to the way in which CCTV was used at The Willow protected the privacy and dignity of service users.

The provider had not always taken all reasonable steps to make sure that risk management plans had been updated when needed or had contained sufficient information to support staff in making sure that service users were kept safe from avoidable harm.

The provider had not made sure that observations of service users had always been undertaken when needed, potentially exposing the service user to an increased level of harm.

Restraint had not always been used in a way that reduced the risk of avoidable harm to service users and in the least restrictive way possible.

The way in which safeguarding incidents had been managed had not always been effective and effective safeguarding policies and procedures to manage allegations of abuse against staff were not in place.

Policies did not always reflect current practice.

The provider had not operated a system to assure themselves of the safety and quality of the services provided at The Willow.

An effective risk management system to make sure that all risks at the Willow had been identified and mitigated as much as practicably possible was not in place.

Systems had not been established to make sure that incidents had been reported, investigated and managed in a way that reduced the risk of similar incidents happening again.

The provider had not always made sure that staff had received the required level of training to undertake their roles effectively.

The provider had taken action to make some improvements following our last inspection. This included making sure that the living quarters of the service user had been cleaned and that service users had access to an independent visitor, allowing them to raise concerns and seek independent advice when needed.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 31 May 2023) and the service had previous breaches of regulations.

At this inspection we found the provider remained in breach of regulations.

The service remains rated requires improvement.

At our last inspection we also recommended that the provider needed to make improvements against other important areas, such as making sure that important information, such as health plans were available for staff to use, as well as making sure that nutrition and hydration needs were better met. At this inspection we found that the provider had not acted on all recommendations and had not made all improvements needed.

Why we inspected

We undertook this targeted inspection to check whether the Warning Notice that we previously served in relation to Regulations 13 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. This inspection was also undertaken to check on a requirement notice that was also issued in relation to breach of Regulation 12, as well as several other recommendations that we made to the provider.

We use targeted inspections to follow up on Warning Notices or to check concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

Enforcement and Recommendations

We have identified breaches in relation to person centred care, privacy and dignity, safe care and treatment, safeguarding, good governance, staffing and duty of candour.

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.

About the service

The Willow is a children’s home which is registered for accommodation for people requiring personal or nursing care as well as treatment of disease, disorder or injury. The service can accommodate one person. The service provides therapeutic psychological support to children and young people with mental ill health and additional needs, such as neuro-developmental disorders. At the time of our inspection there was one person using the service.

Ofsted are the lead regulator for services registered as children’s homes, however, the service was not registered with Ofsted at the time of our inspection.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support: Model of Care and setting that maximises people’s choice, control and independence

Right Care: Care is person-centred and promotes people’s dignity, privacy and human rights

Right Culture: The ethos, values, attitudes and behaviours of leaders and care staff ensure people using services lead confident, inclusive and empowered lives.

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

At the time of inspection, systems had not been fully established to safeguard service users from abuse and improper treatment as safeguarding incidents had not always been effectively managed. Effective safeguarding policies and procedures in place to manage allegations of abuse when made against members of the senior management team were not in place.

The provider did not have an effective policy and procedure for safeguarding vulnerable adults and staff had not received appropriate levels of training in safeguarding vulnerable adults.

The provider had not operated an effective system to make sure that the most up to date policies at The Willow reflected up to date legislation and guidance. Policies did not always reflect current practice or provide enough information to support staff.

The provider had not operated a system to assure themselves of the safety and quality of the services provided at The Willow. Roles and responsibilities of members of the senior management team had not been clearly defined.

The provider had failed to operate an effective risk management system to make sure that all organisational risks at The Willow had been identified and mitigated as much as practicably possible.

Although risk management and positive behaviour plans provided key information as well as strategies to support staff, the provider had not always taken all reasonable steps to make sure that risk management plans had been updated when needed.

There were enough staff to keep young people at The Willow safe.

Staff who we spoke with were committed to treating young people with compassion, kindness and respect. They were passionate about making sure that young people were cared for as best as possible.

The use of restraint had been kept to a minimum and verbal de-escalation strategies had been used successfully on several occasions.

Strategies had been implemented to support young people to access a range of community activities and pursue their own interests.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 14 January 2022) and the service had previous breaches of regulations.

At this inspection we found the provider remained in breach of regulations.

The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

This inspection was prompted by a review of the information we held about this service, information that we had following our last inspection as well as concerns received about how safeguarding concerns had been managed. A decision was made for us to inspect and examine those risks.

During this inspection, we followed up on actions we told the provider to take at the last inspection.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We have identified breaches and have issued a warning notice in relation to safeguarding and good governance. We also identified a further breach in relation to safe care and treatment. Although the provider took actions to address the concerns after the inspection, further improvements are still required.

Please see the action that we have told the provider to take at the end of this report.

Recommendations

We have made a recommendation about cleaning living quarters of young people who live at The Willow.

We have made a recommendation about supporting young people living at The Willow to maintain a balanced diet.

We have made a recommendation about making sure that all important documents such as health plans are available.

We have made a recommendation about the understanding that staff have of Gillick Competence.

We have made a recommendation about access to an Independent Mental Capacity Advocate by young people living at The Willow.

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.

About the service

The Willow is a residential placement for young people aged 13-17-years with complex emotional, mental health and behavioural needs, and neuro-developmental disorders that require specialist psychological therapy and intervention. The service can accommodate one young person at a time. The service is currently registered with the Care Quality Commission (CQC) as a care home, for the regulated activities of ‘accommodation for persons requiring nursing or personal care’ (ANPC) (a regulated activity relating to adults aged 18 years and over) and ‘treatment of disease, disorder or injury’ (TDDI). The Willow does not provide a service for adults, is a service ‘wholly or mainly for children’, and functions as a children’s home. As such, the regulation of accommodation and care provided by The Willow is the responsibility of Ofsted, as the regulator for children’s homes.

Young people's experience of using this service and what we found

Young people were treated with kindness, compassion and respect by staff. We observed positive and containing interaction between staff and young people, which supported dignity and respect.

Environmental risk assessments were individualised and incorporated into young people’s care plans.

Staff supported young people to explore and embrace their identity and provided care that was sensitive to equality and diversity.

Young people received thorough and detailed assessments, plans and interventions that were individualised to their needs and risks.

Support provided to young people enabled them to effectively communicate their needs. Personalised care was having a significant and positive impact on young people’s well-being.

Not all staff had received level three safeguarding children training in accordance with intercollegiate guidance (2019). We have made a recommendation about safeguarding children training.

Staff were not adequately trained to undertake the level of advanced restraint interventions that were sometimes necessary to keep people safe. We have issued a requirement notice about staff training.

Young people were sometimes prevented from accessing some areas of the building, resulting in unintended seclusion. We have issued a requirement notice to ensure that all forms of restraint, seclusion and segregation are the least restrictive possible.

Young people’s living quarters were not always maintained to a good standard or repaired in a timely manner when damage occurred. Although the provider described a clear rationale for the delay, the standard required improvement at the time of the inspection and we have made a recommendation about using assessment to inform the choice of fixtures, fittings and furniture.

The management and organisation of record keeping in The Willow was fragmented and under-developed. We have made a recommendation about the standard of record keeping arrangements.

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

Rating at last inspection

The Willow was inspected but not rated in December 2020 as there were no service users at the time of the last inspection.

Why we inspected

This was a planned, unannounced inspection in response to a service user being accepted into the service.

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

Follow-up

We will request an action plan and meet with the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and Ofsted to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

About the service

The Willow is a residential therapeutic placement, that supports children and young people aged 13-18 years, with mental health and complex neurodevelopmental disorders. It is registered for the regulated activities ‘Accommodation for persons who require nursing or personal care’ and ‘Treatment of disease, disorder or injury.’

Why we inspected

This service first registered with us in July 2020 and had not yet been inspected. We conducted remote monitoring activity, including a telephone conversation with the registered manager and provider. As part of our monitoring we also spoke with a young person who had recently moved out of the home, and their social worker. As a result of the concerns they expressed, we conducted a comprehensive inspection of the service on 8 December 2020.

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

Before our inspection we spoke with a young person who was a former service user and who had recently moved out, to gather their views on the care and support they had received. They told us their privacy and dignity were not consistently respected, as CCTV was installed in their living accommodation. In addition, there were frequent changes in the staff supporting them which they found unsettling, and inappropriate language had been used by staff. We also spoke with the young person’s social worker who told us they had repeated complaints from the young person about their support and the suitability of the environment to meet their needs.

At the time of our inspection there were no young people living at the home receiving the regulated activities. The home was also undergoing modification, prior to a new admission of a different young person. Therefore, we could not fully assess how the provider was meeting the regulations, or test policies and procedures in practice. As a result, we have not provided ratings for the key questions or an overall rating for this service.

During inspection we found CCTV was present but did not cover the person’s private living area. Cameras were installed in communal areas and we found that a consent process was in place.

We found that the provider had a process in place to learn from complaints made by the previous young person. This included a policy that had been developed on staff use of inappropriate language which had been shared with staff.

Staff files we reviewed showed the provider’s recruitment process had not been consistently followed. Some did not contain the required number of references. The provider addressed this immediately following our inspection visit.

The provider informed us a that a different young person was planning to move into the home at the end of December 2020. Staff recruitment was underway, and the provider was carrying out extensive reconfiguration of the home to support the needs of the young person. During our visit the provider acknowledged our concerns that the timescale for admission was too close. As a result, the provider spoke with the local authority who were commissioning the placement to delay the admission until the provider was able to accept the young person.

Mental Capacity Act

The provider explained to us their responsibilities under the Mental Capacity Act 2005 to support young people to make independent decisions and ensure where a person does not have capacity to make a specific decision, to ensure it is made for them in the least restrictive way and in their best interests.. However, as there was no young person receiving the regulated activities, we were unable to test this in practice.

For all services who support people with a learning disability and/or autistic people:

We expect health and social care providers to guarantee that autistic people and people with a learning disability are encouraged and supported to make decisions and exercise choice, their dignity and independence is promoted and to ensure good access to local communities. ‘Right Support, Right Care, Right Culture’ is the guidance CQC follows to make assessments and judgements about services providing support to people with a learning disability and autistic people.

The provider told us they understood these principles. However, as there was no young person receiving the regulated activities, we were unable to test this in practice.

The provider was undertaking extensive modification of the building to meet the needs of a young person planning to move into the home. Pre assessment work was underway with the young person and their care team to ensure the correct support and care would be in place.