The Willows

Updated 29 March 2024

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.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was undertaken 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.

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.

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 and sought feedback from the local authority who work with the service. We used the information the provider had sent us within their monthly condition’s reports. We used all this information to plan our inspection.

The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.

During the inspection

We spoke with 5 people who used the service and 1 relative about their experience of the care provided. Due to people living with dementia, most people were unable to talk with us in detail about the care they received, or the quality of the service provided. Therefore, we used other methods to understand what it was like for people to live at The Willows. This included observing how staff supported people to help us understand people's experiences.

We spoke with 6 members of staff including care staff, the cook, deputy manager, and registered manager. We reviewed a range of records, including 4 people's care records, and multiple medication records. We looked at 3 staff files in relation to recruitment and staff supervision. A variety of records related to the management of the service, including policies and procedures. We looked at a variety of records the provider had shared with us in relation to quality assurance and risk management.

Updated 29 March 2024

The Willows is a residential care home that provides accommodation with personal care for up to a maximum of 32 older people, including people living with dementia. Accommodation is provided in 1 adapted building. During our inspection visit, 25 people lived at the home.

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

Governance systems, management and provider oversight had improved from the previous inspection but there continued to be further improvements required. The provider had introduced systems to help improve monitoring of the service. A number of improvements had been made as a result of these checks. However, the provider had not identified some of the concerns we found. This demonstrated the providers systems continued to require improvement.

People told us they felt safe, but there were occasions when people were placed at risk of unsafe care. Some of these risks were associated with inaccurate and unclear records for medicines and fire risks. Some care plans lacked the information that staff needed to provide personalised and safe 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. The prevention and control of infection was managed safely. There were enough staff to support people’s needs and recruitment checks had been managed safely in line with the providers policy.

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 16 March 2023) 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. This service has been rated requires improvement for the last 3 consecutive inspections.

This service had been in Special Measures since 16 February 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

We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements. 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 has remained Requires Improvement. This is based on the findings at this 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.

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

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

We have identified a continued breach in relation to the management of the home.

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.