The inspection took place on 15 and 16 November 2018. The first day of our inspection visit was unannounced.

Willow Bank Rest Home 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.

Willow Bank House is a residential care home registered to provide care to 63 people, including older people and people living with dementia. The accommodation is split across two floors within one large adapted building. There was a small unit each floor, one known as Angel Bec and the other called Raybold. At the time of our inspection, there were 38 people living at the home.

There was a registered manager in post who was present during our 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.

At our previous inspection on 8 and 15 March and 8 April 2018, we rated the service as 'Inadequate,' and it was therefore placed in 'special measures.' We identified seven breaches of the Regulations. These included the provider’s failure to ensure people were protected from abuse and improper treatment, and people were provided with care in a personalised way from staff who had the support and training to carry out their roles. In addition, the provider had not ensured the premises met people’s individual needs, the principles of the Mental Capacity Act 2005 were adhered to and the overall leadership and governance of the service was effective.

As a result of the inspection, we asked the provider to send us a report explaining the actions they were going to take to improve the service. We also imposed conditions on the provider's registration. These conditions meant the provider was required to tell us, monthly, about how they were auditing aspects of people’s care to ensure people received high quality care. In addition, how the provider supported people’s safety by tracking and analysing incidents and accidents to reduce these from happening again.

At this inspection, the provider showed us sufficient improvements had been made to the service and it was no longer rated as inadequate overall or in any of the key questions. Therefore, the service is no longer in 'special measures.' However, we found the work to improve the service was still ongoing and further time was required to evidence the improvements could be sustained in the longer term which we have reflected in the ratings.

The culture of the service was changing and staff were more confident in recognising and reporting abuse. Staff now had faith in the management team so risks to people’s safety were shared and reduced promptly. The registered manager had made improvements to the processes in place to record incidents and accidents so these were reduced from happening again. They had also improved practices in submitting notifications to us of incidents including abuse as required by law.

Staffing arrangements were now supporting people better so they received safe, effective and responsive care which met their individual needs. There had been a reduction in the number of agency staff used to improve consistency in the care people were provided. Staff were deployed in specific areas of the home to supervise people to promote people's safety and to reduce the risks of people’s safety being compromised.

The systems in place to support the registered manager in monitoring medicines were mostly managed safely. The registered manager understood the improvements required to manage medicines more safely and effectively which included the recommended temperatures at which to store medicines. Staff recruitme

At the last comprehensive inspection on 14 July 2016 the service was rated as ‘Good’ overall. We returned on 9 June 2017 and completed a focussed inspection because we had received some concerns that risks to people were not always managed to keep them safe, and staffing levels may not be sufficient to meet people’s needs. We only looked at Safe and Well led and found they continued to be rated Good in these areas.

This inspection visit was a responsive fully comprehensive inspection because we had received information of concern, specifically related to allegations of poor care and mistreatment. We looked at these concerns as part of this inspection and found evidence that supported what we had been told.

This inspection started on 8 March 2018 and was an unannounced visit. We returned announced on 15 March 2018 so we could speak with more staff, more people, to speak with the provider and to look at the provider’s quality assurance systems.

Because of our concerns, following this inspection, we formally wrote to the provider asking them to tell us how they would address our immediate concerns. The provider sent us their response and action plan and we agreed to complete a third inspection visit to assure ourselves, improvements to the service had taken place. We returned unannounced on 4 April 2018. Some improvements had been made however they required more robust monitoring to ensure the improvements were embedded in staff practice. We continued to find evidence of poor practice despite the provider’s action plan and improved control measures.

Willow Bank House is a residential care home registered to provide care to 63 people, including older people and people living with dementia. People in care homes receive accommodation and nursing and/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. At the time of our inspection visit, 56 people lived at the home. Care was provided across two floors with a small unit on each floor. One unit supported five people living with advanced dementia and was called Angel Beck. The other unit was a female only unit for five people called Raybold.

A requirement of the service’s registration is that they 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 and the associated Regulations about how the service is run. At the time of our inspection visit there was a registered manager in post, but they were on a temporary leave of absence. At the time of our inspection visits, an interim deputy manager was managing the service.

People were not safe. Although some people and relatives said they felt the service was safe, we found risks to people were not managed well and were not always known or clearly understood by staff. Risks to people were not consistently assessed and therefore people were not kept safe from the risk of harm. Recording of risks was not always evident, and in some cases the records had not been reviewed when needed to reflect changes in people's care and support needs. People were not kept safe from risks associated with some aspects of the environment and staff’s lack of attention placed people at unnecessary risk.

The provider had not always ensured staff had the training or knowledge they needed to undertake their roles safely and appropriately. Staff attended training, but there were significant gaps in staffs knowledge about current good practice. Some staff did not feel supported, especially when reporting poor practice. The staff team consistently included agency staff. The mix of agency staff and staff who lacked experience and knowledge of people’s needs meant staffing was not effective

We undertook an unannounced comprehensive inspection of this service on 24 May 2016. After this inspection we received concerns in relation to staffing levels and how people’s care was managed. These included concerns in relation to people’s mealtime experiences and how the development of staff was managed. As a result we undertook a focused inspection to look into those concerns on 12 May 2017. 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 Willow Bank House Residential Home on our website at www.cqc.org.uk

Willow Bank House Residential Home is registered to provide accommodation for up to 63 people who may be older people or living with dementia or physical disability. There were 60 people living at the home at the time of our focused inspection on12 May 2017.

A registered manager was in post at the time of our 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 relaxed when supported by staff. People and their relatives were confident if they raised any concerns about people's safety or well-being staff would take action to support them.

Staff understood risks to people’s safety and took action to meet people’s safety needs. Staff sought and followed the guidance given by external health professionals, so people’s safety would be promoted.

There were enough staff to care for people promptly and to chat to people so they did not become isolated. People were supported by staff to have the medicines they needed in ways which reduced risks of errors.

People and their relatives found the registered manager and senior team to be approachable. The culture in the home was open and relatives were kept informed of developments at the home.

Staff knew what was expected of them and were supported to provide good care.

The registered manager regularly checked the care people received and used their findings to drive through improvement in the care provided. The registered manager recognised people’s needs were changing and worked with other organisations so people would enjoy the best well-being possible as their needs changed.

The inspection took place on 24 May 2016 and was unannounced. Willow Bank House Residential Home provides accommodation for up to 63 people. People living at the home may be older people or have physical or dementia related care needs. There were 60 people living at the home at the time of our inspection.

People had their own rooms and the use of a number of communal areas including a choice of lounges, dining rooms, an internal café and accessible garden areas.

A registered manager was in post at the time of our 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.

Risks to people's safety were understood by staff and staff took action to support people in ways which helped them to stay safe. Staff understood what actions to take if they had any concerns for people's safety or wellbeing. There was enough staff available to support people so their care and safety needs would be met. People were supported to take their medicines so they would remain well.

Staff used their knowledge and skills when caring for people so they would get the support they needed in the way they preferred. Staff worked with other organisations so people's freedom and rights were protected. People were supported by staff to enjoy a range of food and drinks. Where people needed extra support to have enough to eat and drink staff cared for them in the ways people chose. Staff worked with health organisations so people would receive the care they needed as their needs changed.

Caring relationships had been built with staff and the registered manager and people were given reassurance when they needed it. Staff supported people so they were able to make their own choices about what daily care they wanted. People's need for dignity was understood and acted upon by staff.

Staff understood people’s individual care and support needs and their preferences and responded to these. People benefited from living in a home where staff took action when people's needs changed. Complaints about the service were treated as opportunities to develop people’s care further and processes were in place so lessons would be learnt.

People, relatives and staff felt listened to when they made suggestions for developing the home further. Staff understood what was expected of them and were supported through training and discussions with their managers. People benefited from living in a home where links had been developed with the community and other organisations. Regular checks were undertaken on the quality of the care by the provider and registered manager and actions were taken to develop the home further.

An inspector and an inspection manager carried out this inspection. We spoke with four people who lived at the home, four relatives, six staff and the registered manager. We also observed how staff cared for people, and we looked at four care plans to make sure that people had received the right care. The focus of the inspection was to answer five key questions: is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

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

This is a summary of what we found:

Is the service safe?

People we spoke with told us that they felt their relatives were safe living at the home and their needs were met by staff that knew them. Staff also said that they felt people were safe and their needs were met.

Is the service effective?

We observed that people received appropriate care to meet their physical needs and maintain their comfort. All the staff we spoke with told us about the individual needs of the people that used the service. People did not have to wait for help or support with their health care. This meant that people’s needs could be met more effectively.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found that DoLS assessments for some people had been reviewed and there were proper policies and procedures in place.

Is the service caring?

We observed that staff were kind and polite. We found that staff treated the people that lived there with dignity and respect. All the staff we spoke with were able to tell us about people’s individual likes and dislikes. People’s wishes had been respected.

Is the service responsive?

Relatives told us that they felt if people’s needs changed the staff were always quick to respond and contact other professionals so that people's needs could continue to be met safely. We found that the care records showed that people who lived at the home saw other professionals including speech and language therapists and doctors when their health needs changed. The provider had acted appropriately to guidance from other professionals when people’s needs changed.

We found that there was a complaints system in place that ensured that people were listened to. We also saw that the provider encouraged feedback from families so that any concerns or comments could be actioned appropriately.

Is the service well led?

The provider had systems in place to effectively monitor the quality of the service. Regular audits and clear action plans showed that the provider had taken steps to ensure that the quality of the service was constantly being monitored and improved.

We found that there was an effective system in place to ensure that risks were identified and actioned appropriately. During this inspection we found that improvements had been made. The procedure had been improved and there were now further checks by the registered manager and clear actions had been taken when risks or improvements had been identified.

We inspected Willow Bank House over two days. We spoke with fourteen people who lived at the home, five relatives, ten staff and two district nurses. We spoke with the registered manager who was available on the morning of our first inspection day. We looked at three care records and eight staff files.

We found that people who lived at the home were complimentary about the staff that cared for them. One person said, “They are lovely”. However, people told us there were not enough staff and they had not always received the care they had expected. One relative told us, “The staff are wonderful, they are just very busy and don’t have time to do the little things”.

Care and treatment was not always planned and delivered in a way that was intended to ensure people's safety and welfare.

People who lived at the home told us that they had been provided with a choice of suitable and nutritious food and drink.

We looked at staff recruitment files. People are put at risk because staff are not recruited and assessed appropriately.

We looked at staffing levels. We found that there was not enough qualified, skilled and experienced staff to meet people’s needs.

People’s complaints were fully investigated and resolved where possible, to their satisfaction.

Records were kept securely and but we had not been able to access all the records we required during the inspection.

We inspected Willow Bank House in January 2012, and we set compliance actions where we had concerns. We carried out this inspection on 5 September 2012 to check whether compliance had been achieved as part of a routine inspection. During this inspection we found that significant improvements had been made to the outcome areas and compliance actions had been met.

We spent some time during this inspection observing and talking with people who lived at Willow Bank House. We saw that people were well cared for and treated with dignity and respect by all staff. We were told that regular activities took place and saw a game of skittles played during our inspection.

People told us that they were able to make choices about their lifestyle. They could choose when they went to bed at night and what time they got up in the morning. People also said they could have meals outside the planned serving times if they wanted this.

Staff told us they were trained and supported to give people the care and support they needed, and that they knew how to keep people safe.

We saw that people who lived at Willow Bank House were given the opportunity to express their views about the service they received. We saw completed questionnaires that showed where staff had supported people where they had needed help to give their views.

We carried out this review to check on the care and welfare of people. When we visited the home we spoke with nine people who lived there and two relatives. People were very complimentary about the care that they received. We were told “we get everything here”. “First class care”. “I would not want to live anywhere else”. We saw that people were neatly dressed in clean clothes and had clean hair and nails, indicating that staff knew the importance of helping people look their best.

Relatives of people who used the service told us that they were “very pleased with the care provided by the home”. One person told us that they visited the home two to three times each week and that their relative was “well dressed and looked after”. “X (person’s name) is encouraged to join in with activities but most of the time X chooses not to. X is healthier now than when X was living in their flat a few years ago”.

We saw that staff mostly interacted with people who used the service in a friendly, courteous and respectful manner, although there were a number of occasions when we heard care workers addressing people as ‘sweetheart and darling’. We told the registered manager about this at the time of our visit and she said that she would address this with the care workers.

People who used the service told us that the staff were “very nice” and they were kind and spoke to them nicely. We saw that people were very relaxed and at ease with staff.

Our visit found that overall people were experiencing satisfactory outcomes of care. However, we had concerns about the quality of the information contained in the care records, how this was accessed by care workers, care workers’ knowledge of people’s care needs and the failure to put a risk assessment and care plan into place following an incident of physical abuse between two people who used the service.

We looked at the management of medicines for people who used the service and found that people were not fully protected against the risks associated with the unsafe use and management of medicines.

We found that people may be placed at risk of receiving unsafe or inappropriate care and treatment arising from the lack of or conflicting information in their care records.

We looked at how people were safeguarded from potential abuse and found that people may be placed at risk of potential abuse through senior care workers’ lack of recognition of what constitutes abuse, understanding of procedures for reporting and lack of communication amongst staff.

We looked at how the registered manager monitors the quality of the service and found that systems and practice needed to be improved in auditing of the quality of the service. This information could then be used to improve the quality of care and treatment for people using the service and make it more effective.

We spoke with two relatives, ten staff and the registered manager. We were unable to speak with the people that lived there due to the level of their complex health needs. We spent time observing, spoke with staff and relatives, looked at staff records and we also looked at the care records of eight people that lived there.

Is the service Safe?

We looked at eight staff records. We found that the manager had not carried out robust checks to ensure that staff appointed were suitable to work with vulnerable people.

Is the service Caring?

We observed that staff were generally kind and polite. However we did see some instances where people’s individual needs were not met within an appropriate time. People’s privacy and dignity was not always respected.

Is the service Responsive?

We found that the care records showed that people that lived at the home saw other professionals including the district nurses and doctors when their health needs changed. However we found that there were not enough suitably experienced staff to meet people’s needs if they changed.

Is the service Effective?

We observed that people had not always received appropriate care to meet their physical needs and maintain their comfort.

Is the service Well Led?

The quality assurance systems in place were not always effective in highlighting and addressing shortfalls in a timely manner.