5 September 2023
During an inspection looking at part of the service
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.