We completed an unannounced inspection at The Willows on 09 July 2018. At our previous inspection on 08 December 2016 we found that improvements were needed to ensure medicines were managed safely, records were accurate and the systems in place to manage the service were effective. The service was rated as Requires Improvement overall. At this inspection we found that the provider had made the required improvements.

The Willows is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The Willows accommodates a maximum of 12 people. People are supported across two separate houses with each house accommodating up to six people. At the time of the inspection there were ten people using the service. The Willows follow the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

There was a registered manager at the service. 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 received safe care and we found there were enough staff to provide support to people that met their needs. We found that people’s risks were assessed and managed to protect them from the risk of harm and people received their medicines safely. The provider had safe recruitment procedures in place to ensure that staff were of a good character and suitable to support people who used the service. People were protected from infection and cross contamination risks.

People were supported to make decisions about their care and staff sought people’s consent before they carried out support. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. People’s nutritional needs were met and people had positive mealtime experiences. People had access to health care services and advice sought was followed by staff to ensure people’s health and wellbeing was maintained. Staff received training to enable them to support people effectively. The environment was designed and adapted to meet people’s needs and promote independence.

People were treated with dignity and staff were caring and kind. People’s privacy was respected an upheld, people chose to have time to themselves in their private rooms and staff respected their wishes. Staff encouraged people’s independence and understood people’s individual communication needs. Staff supported people to maintain relationships with relatives/friends.

People were supported with interests and hobbies that were important to them. People and their relatives were involved in the planning and review of their care. Staff knew people well, which meant people were supported in line with their preferences. People understood how to complain if they needed to because complaints procedures were in a format that people understood. Plans were in place to gain people’s views of how they wanted to be supported at the end of their life.

Systems were in place to assess and monitor the quality of the service people received. People and staff were encouraged to provide feedback about the service. The registered manager was approachable and supportive to both people and staff and understood the requirements of their registration with us (CQC).

We inspected this service on 8 December 2016. This was an unannounced inspection. At our previous inspection in March 2016, we found that the provider was in breach of some of the legal requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service was rated as ‘requires improvement’ overall. After our last inspection, the provider sent us an action plan showing how they would make the required improvements.

The service is registered to provide accommodation and personal care for up to 12 people. People who use the service have a learning disability. At the time of our inspection 10 people were using the service. However, one of these 10 people was receiving inpatient care at a local hospital.

The service had a registered manager. 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 and associated Regulations about how the service is run.

At this inspection, we found that some improvements had been made and the provider was no longer in breach of the legal requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. However, further improvements were still needed to ensure people’ received care that was consistently safe and well-led.

Improvements were needed to ensure medicines were managed safely and that risks to people’s health, safety and wellbeing were assessed and planned for.

Improvements were also needed to ensure the systems in place to assess, monitor and improve quality were effective.

People were protected from the risk of abuse because staff knew how to recognise and report potential abuse. Safe staffing levels were maintained to promote people’s safety and to ensure people participated in activities of their choosing.

Staff received regular training that provided them with the knowledge and skills to meet people’s needs.

Staff supported people to make decisions about their care and when people were unable to make these decisions for themselves, the requirements of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS) were followed.

People could eat meals that met their individual preferences. People’s health and wellbeing needs were monitored and people were supported to attend both urgent and routine health appointments as required.

Staff knew people well which meant they could interact with them positively and effectively. People were treated with kindness and respect and staff promoted people’s independence, dignity and right to privacy.

People were involved in the assessment and review of their care and staff supported and encouraged people to access the community and participate in activities that met their personal preferences.

People knew how to complain about their care and staff supported people to share concerns about their care. Feedback from people was sought to enable the provider to identify if improvements to care were needed.

Advice was sought from external agencies to monitor the quality of care and recommendations from these agencies were followed to improve care delivery.

The registered manager understood the requirements of their registration with us and they and the provider kept up to date with changes in health and social care regulation.

The inspection took place on 31 March 2016 and was unannounced. This was the first inspection for the service since they had registered with CQC.

The service provides accommodation and personal care for up to 12 people with a learning disability. The accommodation is provided in two units. In unit six there were six people all of whom had moved together from another service in October 2015. In unit eight there were four people who presented with more complex and challenging needs.

The service is required to have a Registered Manager. 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. There was a manager in post but they had not yet registered with CQC. They told us they were in the process of registering with us.

Staff did not always support people safely when they displayed episodes of behaviour that challenged. Not all staff had received training in this area and sometimes inappropriate manual handling techniques were used to manage people’s behaviours which placed them at risk of harm.

People did not always receive their medicines as prescribed and medication errors were not investigated.

Staff did not always know how to support people safely when they displayed episodes of behaviour that challenged. Not all staff had received training in this area and sometimes inappropriate manual handling techniques were used to manage people’s behaviours which placed them at risk of harm. Some staff had received the required training and the provider had plans in place to ensure all staff received the appropriate training so they would know how to handle people more safely.

There was a lack of contingency plans in place to deal with incidents and emergency situations. There was not always learning from incidents in order to make improvements where people's safety was compromised. The procedure for making safeguarding referrals had not always been followed.

People were supported to consent to decisions about their care and support and the provider adhered to the Mental Capacity Act 2005. People were supported to eat and drink and to maintain good health. Timely referrals to health care professionals were made when people's needs changed or they became unwell.

People told us they thought staff were kind and caring with them and it felt like a family atmosphere. We heard staff speaking with people in a respectful way and observed kind and caring interactions .

People did not always receive person centred care and support in the way this had been planned for them. It was not evident where or if people had achieved their goals. Staff supported people to include and involve their family and friends in their lives. People knew how to raise concerns and knew these would be addressed. People had been supported well when they moved between services.

The quality of services provided was not effectively monitored in order to ensure people were receiving appropriate care and support and/or to drive through improvements. The manager was not yet registered with CQC. Staff felt supported by the manager and people and relatives told us the manager was supportive and approachable.

As a result of this inspection we identified two breaches of the health and Social Care Act 2008 as follows -

There was a breach of Regulation 12 - Safe Care and Treatment. There were not always enough staff provided with the right skills and experience to support people in a safe way. People did not always receive their medicines as prescribed and sometimes people's medicines were unavailable. Risks to people's health and safety were not reviewed regularly and risks were not always mitigated.

There was a breach of Regulation 18 of the Registration Regulations 2009 - Notification