This inspection took place on 6 December 2016 and was unannounced. At the last comprehensive inspection in January 2016 the service was rated as Requires Improvement overall. At that time we made requirements relating to the safety of the premises and equipment, and to the failure to submit notifications as required by legislation. When we carried out a focused inspection in June 2016 we found improvements had been made in respect of the safety of the premises and some notifications had been submitted in respect of safeguarding incidents and serious injuries, but we were unable to change the rating at that time.

The home is registered to provide accommodation and care for up to 33 older people, including people who are living with dementia. On the day of the inspection there were 28 people living at the home, including one person who was having respite care. The home is situated in the village of Burton Fleming, close to the town in Bridlington, in the East Riding of Yorkshire and also close to the county of North Yorkshire. The premises has two floors and a passenger lift operates between both levels. The general care unit and the dementia unit are staffed separately.

The registered provider is required to have a registered manager in post and on the day of the inspection there was a manager who was registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were protected from the risk of harm or abuse because there were effective systems in place to manage any safeguarding concerns. Staff were trained in safeguarding adults from abuse and understood their responsibilities in respect of protecting people from the risk of harm.

There was evidence that the registered provider was working within the principles of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and the registered manager had informed the Commission when DoLS applications had been authorised.

There were recruitment and selection policies in place and these had been followed to ensure that only people considered suitable to work with vulnerable people had been employed. On the day of the inspection we saw that there were sufficient numbers of staff employed to meet people's individual needs.

Staff told us they received the training they needed to carry out their roles effectively and confirmed that they received induction training when they were new in post. Some staff told us that they were well supported by the registered manager, although other staff said they were happier with the support they received from the deputy manager.

Senior staff had received appropriate training on the administration of medication. We checked medication systems and saw that medicines were stored, recorded and administered safely.

People who lived at the home and relatives told us that staff were caring and that they respected people’s privacy and dignity. We saw that there were positive relationships between people who lived at the home, relatives and staff, and that staff had a good understanding of people’s individual care and support needs.

A variety of activities were provided to meet people’s individual needs, and people were encouraged to take part. People’s family and friends were made welcome at the home.

People told us that they were happy with the food provided and we observed that there was ample choice. We saw that people’s nutritional needs had been assessed and individual food and drink requirements were met.

The premises were clean and we did not detect any unpleasant odours. The registered manager was aware of how to use signage, decoration and prompts to assist people in finding their wa

We carried out an announced comprehensive inspection of this service on 26 January 2016. We identified two breaches of Regulation in respect of Regulation 18 (Registration Regulations 2009) Notifications of other incidents and Regulation 12 (Health and Social Care Act) Safe care and treatment.

After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach. We undertook a focused inspection on the 29 June 2016 to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to these topics. 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.

The home is registered to provide accommodation for up to 33 older people who require assistance with personal care, some of whom may be living with dementia. On the day of the inspection there were 27 people living at the home, including two people who were having respite care. The home is situated in the centre of the village of Burton Fleming, close to the town of Bridlington, in the East Riding of Yorkshire. It is also close to the county of North Yorkshire. The general care unit and the dementia care unit are staffed separately.

The registered provider is required to have a registered manager in post and on the day of the inspection the manager who was employed at the home was registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our focused inspection on 29 June 2016 we found that the registered provider had followed their plan in respect of the safety of the premises. We toured the premises and saw that the flooring identified as a trip hazard had been replaced. We did not see any other flooring that created a trip hazard. The bed we saw that had a loose headboard had been replaced. A chain across one person’s bedroom door had been replaced with a gate; this was easy to open in the event of an emergency but provided a safe way of deterring people from entering the person's bedroom. This reduced the risk of an accident occurring.

We saw that robust systems had been introduced to monitor the safety of the premises and equipment, and that any concerns identified had been promptly dealt with. This included checks on the safety of beds and flooring. We saw these changes resulted in the registered provider meeting the breach of Regulation in respect of the safety of the premises.

At the inspection on 29 June 2016 we found that the registered manager had followed their plan in respect of the submission of some notifications. Since the previous inspection in January 2016 we had received notifications from the registered manager in respect of deaths, serious injuries, safeguarding and events that stopped the service. However, there was also a legal requirement to submit notifications when DoLS applications had been authorised by the local authority. The registered manager was not aware of this and, although some DoLS applications had been authorised, no notifications had been submitted to CQC.

This was a continued breach of Regulation 18 (Registration Regulations 2009) Notifications of other incidents. We are addressing this breach with the registered provider.

We carried out an unannounced comprehensive inspection of this service on 10 June 2015. Two breaches of legal requirements were found. After the comprehensive inspection, the registered provider wrote to us to say what they would do to meet legal requirements in relation to the breaches of Regulation 15 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches were in respect of insufficient numbers of suitably qualified staff being deployed in order to meet people’s assessed needs, and the premises not being suitable for the purpose for which they were being used.

We undertook this inspection to check that they had followed their plan and to confirm that they now met legal requirements, to look at the overall quality of the service, and to provide a new rating for the service under the Care Act 2014.

The home is registered to provide accommodation for up to 33 people who require assistance with personal care, some of whom may be living with dementia. On the day of the inspection there were 28 people living at the home, including three people who were having respite care. The home is situated in the centre of the village of Burton Fleming, close to the town of Bridlington, in the East Riding of Yorkshire. The general care unit and the dementia care unit are staffed separately.

The registered provider is required to have a registered manager in post and on the day of the inspection there was a manager who was not registered with the Care Quality Commission (CQC). However, they had submitted an application for registration and it was being progressed by the Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

During this inspection we identified two breaches of regulation; this related to the risks associated with the submission of notifications to the CQC and safe care and treatment. You can see what action we told registered the provider to take at the back of the full version of the report.

On the day of the inspection we saw that there were sufficient numbers of staff employed to meet people’s individual needs. New staff had been employed following the home’s recruitment and selection policies and this ensured that only people considered suitable to work with vulnerable people were working at the home.

Some improvements had been made to the environment. On the first floor of the premises [the dementia unit] an additional seating area had been created so there was space for people to sit quietly if they chose to do so, or to meet with family and friends in private. However, we identified some concerns with the environment such as loose bath sides and a damaged bed and these had not been identified in audits undertaken by the service.

People told us that they felt safe whilst they were living at The Willows. People were protected from the risks of harm or abuse because the registered provider had effective systems in place to manage any safeguarding concerns. Staff were trained in safeguarding adults from abuse and understood their responsibilities in respect of protecting people from the risk of harm. Staff also told us that they would not hesitate to use the home’s whistle blowing procedure if needed. Although safeguarding alerts had been submitted to the local authority when required, the CQC had not received notifications from the registered provider.

Staff confirmed that they received induction training when they were new in post and told us that they were happy with the training provided for them. Staff had received training on the administration of medication and people told us they were happy with how they received their medicines.

People told us that staff were caring

This inspection took place on 10 June 2015 and was unannounced. This inspection incorporated a comprehensive inspection and a responsive inspection to follow up on requirements made at the last inspection.

We previously visited the service on 23 October 2014 and we found that the registered provider did not meet all of the regulations we assessed. We made a requirement in respect of two breaches of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010; this is now Regulation 12 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found that staff did not use safe lifting techniques when assisting people to transfer and that staff did not have access to up to date guidance or published research evidence in respect of good practice in relation to care and treatment. In December 2014 the provider wrote to us to say what they would do to meet legal requirements. At this inspection we found that the breaches of regulation identified at the last inspection were now met.

The Willows is registered to provide personal care and accommodation for up to 33 older people, some of whom may have a dementia related condition. There is a separate area of the home designated for people who are living with dementia. The home is located in Burton Fleming, a village that is close to Bridlington, a seaside town in the East Riding of Yorkshire. It is also close to the North Yorkshire boundary and both local authorities commission a service from the home. Most people have a single bedroom and some bedrooms have en-suite facilities. On the day of the inspection there were 25 people accommodated at the home.

The registered provider is required to have a registered manager in post and on the day of the inspection there was a manager in post who had registered with the Care Quality Commission (CQC) on 7 December 2012. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found that the premises were not suitable to meet the needs of people who lived at the home. There was insufficient space for people accommodated on the first floor to live comfortably, to walk around the home freely and have access to outdoor space.

We saw that there were insufficient numbers of staff on duty to meet the needs of people who lived at the home and to enable staff to spend one to one time with people.

Two breaches of regulation were identified at this inspection. We found there were insufficient numbers of staff employed to ensure that the care and support needs of people who lived at the home could be met, and that the design of the premises was not suitable to meet the needs of people who lived at the home. You can see what action we told the provider to take at the back of the full version of the report.

There was a lack of quality auditing, and feedback from quality surveys was not collated or analysed to identify any improvement that needed to be made to ensure that people received care that was safe and promoted their well-being. We made a recommendation in respect of this shortfall.

People told us that they felt safe living at The Willows. Staff had completed training on safeguarding vulnerable adults from abuse and were able to describe to us the action they would take if they had concerns about someone’s safety. They said that they were confident all staff would recognise and report any incidents or allegations of abuse. However, we saw that some products that could have caused harm to people were not stored safely and we made a recommendation in respect of this shortfall.

We observed good interactions between people who lived at the home and staff on the day of the inspection. People were supported to make their own decisions and when they were not able to do so, meetings were held to ensure that decisions were made in the person’s best interests. If it was considered that people were being deprived of their liberty, the correct authorisations had been applied for.

People’s nutritional needs had been assessed and people told us that they were satisfied with the meals provided at the home. People told us that they had ample choice and their special diets were catered for.

New staff had been employed following the home’s recruitment and selection policies to ensure that only people considered suitable to work with vulnerable people had been employed. People who lived at the home and relatives told us that staff had the skills they needed to carry out their roles. Staff confirmed that they received induction training when they were new in post and told us that they were happy with the training provided for them.

Medicines were administered safely by staff and the arrangements for ordering, storage and recording were robust, although the auditing of controlled drugs (CDs) was infrequent.

People told us that the home was maintained in a clean and hygienic condition but we recommended that the prevention and control of infection was audited to ensure that this was continually monitored.

There were systems in place to seek feedback from people who lived at the home, relatives, health and social care professionals and staff, although these were not currently analysed and collated to identify improvements that needed to be made. People’s comments and complaints were usually responded to appropriately although details were not always recorded in the complaints log.

This inspection took place on 23 October 2014 and was unannounced. We previously visited the service on 23 June 2014. We found that the provider did not meet the regulations that we assessed in respect of staffing levels and we asked them to take action. At this inspection we found that appropriate action had been taken to make the identified improvements.

The service is registered to provide personal care and accommodation for 33 older people, and has a separate unit for people with a dementia related condition. The units are staffed separately.

The provider is required to have a registered manager in post and on the day of the inspection there was a manager registered with the Care Quality Commission (CQC); they had been registered since 7 December 2012. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us that they felt safe living at the home. However, we observed staff moving and transferring people inappropriately.  This was a breach of Regulation 9 of the Health and Social Care Act 2008. You can see what action we told the provider to take at the back of the full version of the report.

Staff received appropriate training although a more robust system was needed to record people’s induction training when they were new in post and some staff still needed to complete training on safeguarding adults from abuse.  We did not see any evidence that care for people living with dementia was based on published research or guidance. This was a breach of Regulation 9 of the Health and Social Care Act 2008. You can see what action we told the provider to take at the back of the full version of the report.

Staff had been recruited following the home’s policies and procedures to ensure that only people considered suitable to work with vulnerable people had been employed. Staffing levels had increased and this meant that there were sufficient numbers of staff to meet the needs of people who lived at the home.

People’s nutritional needs had been assessed and people told us that they were satisfied with the meals provided by the home. We found that medicines were safely managed.

We observed good interactions between people who lived at the home and staff on the day of the inspection. People told us that staff were caring and this was supported by the relatives we spoke with.

People’s comments and complaints were responded to appropriately and there were systems in place to seek feedback from people and their relatives about the service provided.

The management arrangements at the home were more consistent than we had seen at the last inspection. A deputy manager had been appointed and this meant that there was a manager on duty over a seven day period. People who lived at the home, relatives and staff told us that the home was well managed. 

Our inspector visited the service as we had received information stating that there were insufficient numbers of staff to effectively care for the people who lived at the home, and that the manager was frequently absent. The information collected by the inspector helped answer our five questions: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with staff and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

On the day of the inspection we found that the manager's role had not been covered during her absence and this left care staff with insufficient time to provide safe care to the people who lived at the home.

Is the service effective?

We saw that people had care plans in place that recorded their dependency levels and that care staff were aware of people's individual needs.

Is the service caring?

We saw that staff were kind and compassionate when they supported the people who lived at the home. We observed a member of staff assisting someone to eat their lunch and that this was carried out with dignity and respect.

Is the service responsive?

We saw that staff were unable to meet the needs of people who lived in the residential unit promptly because they also had responsibility for answering the telephone, the administration of medication, preparation of the evening meal and laundry duties.

Is the service well-led?

The manager was absent of the day of the inspection as they had been working overnight elsewhere. We noted that some tasks could not be carried out in the manager's absence, for example, service users did not have access to their money.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to staffing levels.

We spoke with two people who lived at the home, three members of care staff and the cook as part of this inspection.

We checked the care records for three people who lived at the home and saw that they had been reviewed and updated consistently so that staff had up to date information about the people they cared for. People who we spoke with were positive about the care they received and described staff as "Pleasant" and "Patient".

People received nutritious meals that could be adapted to meet their specific dietary requirements and they were consulted about the menu in resident meetings. Drinks were provided regularly throughout the day.

Staff had received training on safeguarding adults from abuse and the people who lived at the home told us that they felt safe living there.

Satisfactory recruitment and selection procedures had been followed to employ staff to ensure that people employed were considered suitable to work with vulnerable people. Most of the time there were sufficient numbers of staff on duty.

People told us that they were consulted about the care and support they received. They told us about the resident meetings and one person said, “You can say anything you like at the meetings”. Quality audits had been carried out to monitor that systems in the home were being followed consistently to ensure that people received safe and appropriate care.

We did not speak to people who lived at the home during this inspection. We toured the premises to check on cleanliness and hygiene standards and to observe staff practice. We also spoke with the general manager, the registered manager and the infection control lead to assist us in making a judgement about compliance.

We found that action had been taken to improve hygiene standards. One bathroom had been refurbished and the flooring in the upstairs area of the home where we had previously identified unpleasant odours had been replaced. We did not detect any unpleasant odours during this inspection.

Toilets and bathrooms had been fitted with soap dispensers and paper towel holders to promote good hand hygiene.

Staff had undertaken appropriate training and an infection control lead had been appointed.

The infection control lead and the manager had devised new cleaning rotas that were designed to ensure all areas of the home would be cleaned on a regular basis.

We discussed some areas for improvement with the manager, such as colour coding cleaning equipment and segregating areas of the laundry room. We also reminded the manager about the need to inform CQC of any outbreaks of infectious diseases.

On the day of our visit we spent time in one of the lounges observing the interaction between staff and three people who lived at the home. We also spoke to one person who lived at the home and chatted to others.

We saw that staff tried to obtain a person's consent prior to assisting them with personal care or eating/drinking.

We saw that assessments, care plans and risk assessments were an up to date record of a person's care needs. People told us that they were happy at the home. One person said, “I have lived her for a long time and the staff look after me well. They are pleasant and always try to help me if they can”. People said that staff responded quickly if they rang the call bell. We saw that there were sufficient numbers of staff on duty to care for the people who lived at the home.

We observed the administration, storage and recording of medication and found that staff followed the home's policies and procedures.

We were concerned about certain aspects of cleanliness and infection control at the home. Some areas needed to be refurbished to provide accommodation that could be maintained in a clean and hygienic condition and the infection control policy did not adhere to current guidelines.

We saw that people who lived at the home or their representatives were told about the complaints procedure and records evidenced that complaints were dealt with appropriately.

Some people living at the home had complex needs and we were unable to verbally communicate with them about their views and experiences. Due to this we have used a formal way to observe people in this review to help us understand how their needs were supported. We call this the ‘Short Observational Framework for Inspection’ (SOFI).