This inspection took place on 13 and 14 December 2018 and was unannounced. The previous inspection was completed in October 2017 and the service was rated overall as requires improvement. There were two breaches of regulation identified at the previous inspection. These were because risks to people’s safety were not being appropriately mitigated and statutory notifications had not always been submitted to CQC when required.

At this inspection we found that the required improvements had been made and the service is now rated good overall.

The Willows is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a 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 can accommodate up to 10 people and at the time of the inspection there were nine people living there. The home is three-storey, with bedrooms and a bathroom on each floor. Bedrooms were spacious and personalised. The ground floor had a staff office, the kitchen, dining room, and living room. There was also a games room with a pool table, computer, and garden access.

The care service has been developed and designed in line with 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.” Registering the Right Support CQC policy

There was a registered manager in post and available throughout the inspection. 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 supported to achieve positive healthcare outcomes. There was a reduction in medicines administration due to improved positive behaviour support plans being developed and followed. Medicines were stored, recorded and administered safely.

Risks to people’s safety were identified and assessed to ensure people could maintain their independence. Risk assessments were personalised to people’s interests and the activities they took part in.

The staff team learned from any incidents, and reflective meetings took place. These were to help equip staff with the skills needed to support people’s behaviours. Positive behaviour support plans were in place and these detailed how staff could identify changes in the person’s behaviours, as well as what support was required.

Complex behaviour and communication needs were understood and supported by the staff team. These were documented in person-centred care plans. People’s emotional support needs were met by a kind and supportive staff team.

Health and social care referrals were made in a timely manner and where appropriate. Records showed that input was tailored to people’s needs. One person met with a nutritionist and went shopping to identify foods suitable for their diabetic needs. Another person was supported to meet with a community health care professional, to discuss relationships. Information from professionals was included in people’s care and support plans.

There were suitable numbers of trained staff available to support people’s needs. There were safe staff recruitment and selection processes.

Staff understood the principles of the Mental Capacity Act 2005 (MCA) and could apply these to the support that they provided to people. People’s capacity to consent to specific decisions was assessed when required.

Information was provided to people in accordance with the Accessible Information Standard 2016. People knew how to raise concerns and had access to an independent mental capacity advocacy service for ‘drop-in

The Willows is a care home which provides accommodation and personal care for up to 10 people with autism, a learning disability or mental health needs. At the time of our inspection seven people were living at The Willows.

This inspection took place on 10 October 2017 and was unannounced. We returned on 17 October 2017 to complete the inspection.

The service did not have a registered manager in post 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 and associated Regulations about how the service is run.

The previous registered manager left their post at the service in September 2017. A new manager was in post and was available throughout the inspection. The manager said they were aware of the need to submit an application to be the registered manager and needed to obtain the information necessary to make the application. The provider had a condition of registration that a registered manager must be in post at The Willows and was therefore not meeting the conditions of their registration at the time of the inspection. We will monitor this and will consider taking action if the service continues to operate without a registered manager.

At the last comprehensive inspection in December 2016 we identified that the service was not meeting Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because medicines were not being managed safely. At this inspection we found the systems for managing people’s medicine had improved and staff were providing safe support to meet the requirements of the regulation. However, further work was required to ensure staff always kept accurate records of the support they provided to people in relation to medicines.

Staff did not always take action to support people to manage risks they faced. Staff did not provide effective support to a person who had left the service when distressed. The lack of action by staff had increased the risks faced by the person. Records had been completed by staff involved in incidents, but the incident recording process did not include details of actions taken by the management team in response to the incident. The manager was aware of the shortfalls and was taking action to address them.

The provider had not ensured notifications were always submitted to the Care Quality Commission when required. Incidents in which abuse has happened, there is an allegation of abuse or those that are reported to or investigated by the police must be reported to CQC. This is to ensure CQC can monitor how the service is operating and take any follow up action that is necessary.

People who use the service were positive about the support they received and praised the quality of the staff and management. People told us they felt safe when receiving care and were involved in developing and reviewing their support plans. Systems were in place to protect people from abuse and harm and staff knew how to use them. One person commented they liked that there were staff awake at night so they can get help if needed. Another person told us they felt safe and said they would talk to staff if they had any concerns.

Staff were appropriately trained to give them the skills necessary to meet people's needs. Staff received a thorough induction when they started working for the service. They demonstrated a good understanding of the values and philosophy of the service.

The service was responsive to people’s needs and wishes. People had regular group and individual meetings to provide feedback and there was a clear complaints procedure.

The management team assessed and monitored the quality of care. The service encouraged feedback from people, which they used to make improvements. The manager was aware of the s

We carried out this inspection on 10 December 2016 and it was announced 24 hours beforehand to ensure that staff and records would be available during the inspection. When The Willows was last inspected in September 2015 there were no breaches of the legal requirements identified.

The service is a care home without nursing and provides care and support for up to a maximum of 10 people who have either learning disabilities and/or complex care needs. On the day of our inspection there were seven people living at the service.

The service has 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.

Improvement was required in relation to processes for safe medicines management.

The provider had quality monitoring systems in place which were used to bring about improvements to the service. These had not been fully effective in identifying the issues in relation to medicines management.

The staff had received training regarding how to keep people safe and they were aware of the service safeguarding and whistle-blowing policy and procedures. Staffing was arranged in a flexible way to respond to people’s individual needs.

People were provided with regular opportunities to express their needs, wishes and preferences regarding how they lived their daily lives. This included meetings with their social worker or designated member of staff who was their keyworker.

Each person was supported to access and attend a range of working, educational and social activities. People were supported by the staff to use the local community facilities and had been supported to develop skills which promoted their independence.

People’s needs were regularly assessed and resulting support plans provided guidance to staff on how people were to be supported. Support in planning people’s care, treatment and support was personalised to reflect people’s preferences and personalities.

The staff had a clear knowledge of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). These safeguards aim to protect people living in care homes from being inappropriately deprived of their liberty. These safeguards can only be used when a person lacks the mental capacity to make certain decisions and there is no other way of supporting the person safely. Meetings had been arranged in order to enable people’s best interest to be assessed when it had been identified that they lacked the capacity to consent to their care and treatment.

There was a robust staff recruitment process in operation designed to employ staff that would have or be able to develop the skills to keep people safe and support people to meet their needs.

Staff demonstrated a detailed knowledge of people’s needs and had received training to support people to be safe and respond to their support needs.

The service maintained daily records of how peoples support needs were meet and this included information about medical appointments for example with GP’s and Dentists.

Staff respected people’s privacy and we saw staff working with people in a kind and compassionate way responding to their needs.

There was a complaints procedure for people, families and friends to use and compliments could also be recorded.

We saw that the service took time to work with and understand people’s individual way of communicating in order that the service staff could respond appropriately to the person.

We found one breach of regulations at this inspection. You can see what action we told the provider to take at the back of the full version of the report.

At the comprehensive inspection of this service in December 2014 we identified four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. After the comprehensive inspection, the provider wrote to us with an action plan of what they would do to meet the legal requirements in relation to the breaches. We undertook a focused inspection on the 03 September 2015 in line with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We checked that they had met their action plan for improvements. At this inspection we found the provider had made the required improvements.

People who use the service were now protected from the risks associated with the unsafe management of medicines. The provider had ensured that people were protected from unsafe or unsuitable premises. Mental capacity assessments were now in place for people and staff demonstrated an understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). People took part in a wide range of meaningful activities.

This report covers our findings in relation to the improvements required and we have changed the rating since the inspection in December 2014 to reflect this.

The Willows provides accommodation and personal care for up to ten people with a learning disability or mental health need. The home is in a rural setting in Wiltshire. The home had a registered manager in place. 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.

The Willows provides accommodation and personal care for up to ten people with a learning disability or mental health issues. At the time of our visit there were seven people living at the home. The Willows is situated on the outskirts of Warminster in Wiltshire. Bedrooms are on the ground and first floor. There are two shared bathrooms and some bedrooms have their own washing facilities.

During our last inspection on 09 April 2014 we found the provider to be in breach of Regulation 12 Cleanliness and infection control. This was because measures had not been taken to ensure adequate standards of cleanliness and hygiene in relation to the bathrooms. The provider wrote to us with an action plan of improvements that would be made. During this inspection we found the provider had made the required improvements to the cleanliness of the bathrooms, however we found further concerns around the standard of cleanliness within other areas of the home.

The service did not have a registered manager in place. 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 the time of our inspection, the home was being supported by an interim manager who was a registered manager within another of Exalon Care limited group homes. The provider had notified us that a new manager had been recruited and would be starting at employment at The Willows during the first week of January 2015.

People who live at The Willows told us they either felt safe all of the time or most of the time. There were sufficient number of staff to meet peoples needs. Staff were confident in their knowledge of recognising and reporting safeguarding concerns

The standard of cleanliness within the home was not consistent. Some areas such as window sills, skirting boards and doors were not clean. The floor of a linen cupboard was dusty. Not all staff followed safe food handling practices. The provider’s system for infection prevention and control was not in accordance with the Code of Practice for health and adult social care. The Code of Practice applies to registered providers of healthcare and adult social care and sets out the standards of infection prevention and control required under the Health and Social Care Act 2008.

We found errors in the recording of the administration, storage and disposal of medicines. The lack of an accurate record of medicines held in the home increased the risk that medicines may be misused.

Some areas of the home were not safe. There were electrical fuse boxes in two of the bedrooms which had not been locked. At the top of a flight of stairs, two adjacent doors opened up towards each other. There was a risk of injury either through trapped fingers or from losing balance and falling down the stairs. The provider had not ensured people were protected from unsafe or unsuitable premises.

Staff did not fully understand their responsibilities in relation to the Mental Capacity Act 2005 and Deprivation of Liberty (DoLS) which may impact on their ability to protect people’s rights.

People told us they enjoyed the food and had enough to eat and drink. People had full access to the kitchen and could prepare their own meal or snack if they wished. Staff treated people with respect and protected people’s privacy and dignity. Staff supported people to make their own decisions and were aware of people’s likes and dislikes and preferences for their care routines

Each person had a care plan which included information on maintaining people’s health, their daily routines and personal care. Health and social care professionals were involved in people’s care.

There was a lack of planning and availability of meaningful activities which people could take part in. People’s wellbeing was not promoted due to a lack of activities to meet their social, mental and emotional needs.

Staff received support and training to do their job and told us that the management team were approachable. There were systems in place to ensure that staff received support through supervision and an annual appraisal to review their on-going development. Supervision and appraisals are processes which offer support, assurance and develop the knowledge, skills and values of an individual, group or team. The purpose is to help staff to improve the quality of the work they do, to achieve agreed objectives and outcomes.

People told us they knew how to make a complaint if they wished to. People and staff felt they could approach the manager if they were not happy with the care or service provided.

The quality assurance process in place for the medicine and infection control audits was not effective. There was a lack of detailed information to clearly identify, assess and manage the risks relating to the health, welfare and safety of people who use the service.

There were several breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

There is no registered manager at the home. The previous registered manager now works for another branch of the organisation. The deputy manager is acting up as the manager and is in the process of applying to be the registered manager of the home.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask.

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well-led?

This is a summary of what we found –

Is the service safe?

People were treated with respect and dignity by staff. People told us that they were happy living at the home and that staff treated them well. People were cared for by staff that knew and understood how to support people in a consistent and safe way.

People’s safety was protected and promoted because the service obtained advice and support from other health and social care services that people required in order to meet their needs effectively.

Improvements had been made in the maintenance of the home so that people were protected against the risks of unsafe or unsuitable premises. Further work was being undertaken to make improvements to the environment.

Although there had been improvements in ensuring a cleaner environment had been maintained, the service was not clean and hygienic in all areas. Bathing equipment and facilities were damaged and unsuitable for use. This meant they could not be cleaned properly to help prevent cross infection to the people using the service.

We have asked the provider what they are going to do to meet the requirements of the law in relation to protecting people from the risk of infection.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. Although no applications had needed to be submitted relevant staff had been trained to understand when an application should be made, and in how to submit one. This meant that people were kept safe from harm.

Is the service effective?

People received appropriate care and support because there were effective systems in place to assess, plan, implement, monitor and evaluate people’s needs. People were involved throughout these processes. This ensured their needs were clearly identified and the support they received was meaningful and person centred.

People were supported in obtaining an advocate if needed, this meant that when required people could access additional support.

People told us they were happy living at the home and helped to make decisions about their lifestyle. Through our observations we saw that staff had built good relationships with people and that people were comfortable in the company of staff.

Is the service caring?

Staff had a good awareness of individuals' needs and treated people in a warm and respectful manner. Staff were knowledgeable about people's preferences and interests and encouraged people to be involved in meaningful activities.

There was a constant interaction between staff and people in the home; people were involved in conversations with the staff. We observed staff paid attention to people who needed additional support ensuring they were understood.

Is the service responsive?

Systems were in place to make sure that staff learnt from significant events including accidents and incidents. Discussion took place at staff meetings so that information was communicated about further action required to help prevent reoccurrence.

People’s care was reviewed regularly so that any changes were communicated to the staff team and families. People were involved with their care. One person had requested a copy of their support plan and we saw this was being prepared for them.

People completed a range of activities in and outside the service regularly. We observed various meaningful activities people were involved with that were chosen by the people themselves.

Is the service well-led?

The service had an effective quality assurance system and shortfalls were identified. Planning was in place to make improvements. People who used the service, their relatives and visiting professionals were asked for their views on a regular basis to help ensure their views contributed towards improvements and further development of the service.

The manager and staff reviewed people's needs and ways to improve these. One way they had achieved this was through monthly meetings. This meant that people had been empowered to make positive changes and had been involved in developing the service.

Before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. One person living at the home said "I choose myself".

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. One person living at the home said "staff are nice". A number of people living at the home described how they were able to participate in a range of activities of their choice.

People who use the service, staff and visitors were not protected against the risks of unsafe or unsuitable premises.

People were not cared for in a clean, hygienic environment.

There were enough qualified, skilled and experienced staff to meet people’s needs.

People were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained.

People’s privacy and dignity were respected. People were supported to find work and pursue activities which reflected their interests.

We asked people what it was like living in the home. One person told us “it’s not bad. It’s brilliant!” Another person said “it’s good.”

We saw people required varying levels of supports. Staff assisted people to maintain their independence.

The menu offered two hot options of meat, fish and vegetables and a vegetarian alternative. People told us the food was generally good.

Staff were knowledgeable on recognising and reporting abuse.

Staff were suitably qualified and appropriately supported to work effectively within their role.

The provider had an effective system in place to monitor the quality of the service.

People told us about their activities and how they spent their time. People were involved in the community. They told us about the different jobs and household chores that they were responsible for.

People's health and welfare was supported with detailed care planning and regular review.

People and staff got on well together. We saw that people were well supported by staff in a professional and expereinced way. Members of staff told us they felt well supported by the manager and deputy.

Although different aspects of the services provided are reviewed and people's views sought, there was no overall report and plan for improving the service for people's health and wellbeing.