27 June 2023
During an inspection looking at part of the service
The Willows is a nursing home providing personal care and accommodation for up to 48 people across 2 floors. Each floor has its own communal areas. The service supports people with general nursing needs on the ground floor and people living with Dementia on the first floor. At the time of our inspection there were 38 people using the service.
People’s experience of using this service and what we found
Improvements were still being made to develop effective systems to monitor the care provided to people and to ensure people’s records reflected their needs. These systems were being reviewed and amended but needed further time to be embedded to help drive improvements in the home. The registered manager demonstrated a commitment to delivering improvements and had an improvement plan in place which was updated to include the feedback we shared during and following our inspection.
Systems were in place to review incident and accidents, and action was taken to learn lessons from these. This included a recent incident where action has been taken to reduce the risks of this event happening again. Improvements were made during the inspection to increase staffing at peak times during the day to ensure people received the support they needed.
People were supported by staff who had been recruited safely received training and understood how to protect people from abuse. People received their medicines when they needed them. People had access to healthcare professionals to ensure their healthcare needs were monitored and met.
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 those important to them, were involved in planning their care and were supported to provide feedback about the way the service was managed. People and their loved ones were happy with the service provided and felt able to approach staff and the registered manager.
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 April 2019.) and there were breaches of regulation. 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.
The service remains rated requires improvement. This service has been rated requires improvement for the last 3 consecutive inspections.
Why we inspected
This inspection was prompted by a review of the information we held about this service. It was also prompted in part due to concerns following an incident where a person had developed sore skin. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
We found no evidence during this inspection that people were at risk of harm from this concern. The provider had taken action to mitigate the risks, and this had been effective.
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 remains requires improvement based on the findings of this inspection.
We have found evidence that the provider needs to make improvements. Please see the safe, and well led sections of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Willows nursing home on our website at www.cqc.org.uk.
Enforcement
We have identified a breach in relation to the overall governance of the service. Please see the action we have told the provider to take at the end of this report.
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.