About the service: Willow House is a residential care home. It provides accommodation and personal care for up to 30 older people some of whom may be living with dementia or have a physical frailty. At the time of the inspection there were 25 people living at the home.

People’s experience of using this service: People told us they were happy living at Willow House, they felt safe and well cared for. Staff were seen to be kind, caring and knew people and their relatives well.

Relatives and staff told us the home had improved since the last inspection, which they attributed to the new management team and spoke positively about the changes that had taken place.

We found improvements had been made with regards to the safety, effectiveness and management of the home. However, time was needed time to fully embed those changes and show sustained improvement.

The registered manager was aware of their responsibilities under the duty of candour, that is, their duty to be honest and open about any accident or incident that had caused, or placed a person at risk of harm. However, we noted the home had been slow to tell us (CQC) about specific events which they were legally required to do.

People received their prescribed medicines on time and in a safe way. However, where people had been prescribed medicines they only needed to take occasionally guidance provided to staff was not always clear. We have made a recommendation in relation to medicines.

People were supported to have maximum choice and control of their lives; however, we have recommended the registered manager reviews all documentation in relation to the recording of best interests decisions.

People received a service that was safe. The registered manager and staff understood their role and responsibilities to keep people safe from harm, protect people from discrimination and ensure people's rights were protected.

Risks had been appropriately assessed and staff had been provided with information on how to support people safely.

People, along with family members were encouraged to share their views about the care people received through regular reviews and meetings.

There were sufficient numbers of staff employed to ensure people’s needs were met. Staff had time to sit and engage people in conversation and to support people’s involvement in social activities.

Recruitment practices were safe and staff were well-trained.

The home was clean, well maintained and people were protected from the risk and/or spread of infection as staff had access to personal protective equipment (PPE).

Rating at last inspection: The home was previously rated as ‘Required Improvement.’ The report was published on the 29 August 2018.

Why we inspected: This inspection was scheduled based on the previous rating.

Follow up: We will continue to monitor the home through the information we receive until we return to visit as per our re-inspection programme.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

This unannounced inspection took place on 8 and 10 January 2018. Prior to the inspection we had received concerns about how the home managed people’s medicines, whether people were having their nutritional and hydration care needs met, staffing levels as well as the management of the home, and attitude of some staff.

Willow House 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. Willow House is registered to provide personal care and support for up to 30 older people some of whom may be living with dementia or have a physical disability. The home does not provide nursing care; people living there would receive nursing care through the local community health teams. At the time of the inspection there were 17 people living at the home.

Willow House has been inspected five times since May 2015. At each of these inspections, we found breaches of regulation and the home was rated as ‘Requires Improvement’.

At this inspection, we found further improvements had been made, although some improvements were still needed. People told us they felt safe and happy living at the home, however we found that risks to people were not sufficiently well managed. Support was not always provided in a person centred way: governance systems have not been sufficiently robust over a period of the last three years to identify and bring about the required improvements.

The home did not have a registered manager. A new manager had been appointed; they had applied to be registered with the Care Quality Commission and were available throughout this inspection. They were referred to as the manager throughout this report. A registered manager is a person who has registered with the Care Quality Commission to manage the home. 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 home is run.

The home’s quality assurance and governance systems were not effective. Although some systems were working well and improvements had been made since the last inspection, other systems had not identified the concerns we found during this inspection.

Risks to people’s health and wellbeing were not always managed safely and the systems in place to minimise risks to people’s health and safety were not always understood by staff. Where risks had been identified, action had not always taken to minimise these risks. For example where guidance had been provided by external professionals, it was not always followed. This placed people at increased risk of choking, developing pressure ulcers and increased risk of falls.

Whilst some premises checks had been completed we noticed a number of bedrooms windows were not properly restricted. There was no evidence the provider had carried out any form of risk assessment in relation to needs of people currently living at the home and the risks posed by having unrestricted windows that were easily assessable. Following the inspection, the manager gave assurance that following a risk assessments all windows identified were now being appropriately restricted.

Some improvements were needed to the homes recruitment processes to ensure people were kept safe. We looked at the recruitment files for ten staff. We found some recruitment checks had been carried out, but others had not. For example, one person did not have a DBS certificate in place and had been working at the home since November 2017. This meant the provider could not be assured they had taken sufficient action to ensure staff were of good character. Following the inspection, the manager assured the commission that the persons DBS was now in place.

Some people’s care and support was not always appropriate, did not meet their need

Willow House is a care home registered to provide personal care and accommodation for up to 30 older people. The majority of people who lived in Willow House were living with a form of dementia.

We carried out a previous inspection of this service on 10 May 2016 where we identified breaches of regulation. We found improvements were required in relation to the management of medicines, in relation to following specialist guidance, records management and the quality assurance systems. At this inspection on 7 and 10 February 2017, we found some action had been taken to respond to our concerns in relation to medicine management, but found action was still required to further improve this, and we identified other areas of concern.

This inspection took place on 7 and 10 February 2017 and the first day was unannounced. At the time of our inspection there were 20 people living in Willow House. People had a range of needs, with most people at the home living with a form of dementia.

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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The timing of this inspection was brought forward following a number of safeguarding concerns as well as information of concern being received. These concerns related to people not being cared for safely, one person having their call bell taken away by staff, people’s individual needs not being responded to and people not being treated with respect. We found evidence of most of these concerns during our inspection but did not find any evidence of staff failing to treat people with respect.

Since May 2015 Willow House has been inspected four times and at each of these inspections we found breaches of regulation and the service was rated requires improvement. Although the provider was working hard to improve systems and practices at Willow House, concerns relating to people not always receiving safe care and treatment and quality assurance processes being ineffective at identifying concerns persisted. We found the systems in place to monitor the quality and safety of people’s care were not effective and had not identified significant issues.

People who lived in Willow House were not always safe. Sufficient action had not always been taken to protect people from the risks of harm. Risks to people had not always been identified and risk assessments were sometimes not completed, or did not provide any guidance on how staff were to minimise or manage risks. This included risks relating to falls, weight loss, seizures, suicidal thoughts, aggressive behaviours and people’s behaviours which could pose risks to themselves.

The registered manager, senior management and staff did not have a good understanding of the Mental Capacity Act 2005 (MCA). Where one person who had capacity to make decisions, had expressed their wish for bed rails not to be used on their bed. We found that bed rails were regularly being used on their bed. There was no evidence this person’s consent had been sought and recorded when these had been used.

People did not always receive care which was person centred and reflected their individual needs. People’s care plans did not always contain sufficient detailed information for staff to meet people’s needs. In one instance, a person did not have a completed care plan after having been living in the home for a period of almost seven weeks. This person had specific needs relating to their personal care and staff had not been instructed on how to meet these needs. Records showed this person’s needs had not been met in the way they required on a number of occasions.

The systems in place for assessing and monitoring the quality and safety of the care at the home had not

Willow House is a care home which provides accommodation and personal care for up to 30 people. The home provides care for older people, the majority of which are living with dementia. People who live at the home receive nursing care through the local community health teams.

There was a registered manager in post. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

This inspection took place on 10 May 2016 and was unannounced. At the time of our inspection there were 19 people living in the home. People had a range of needs with some people being more independent than others. Some people had significant needs relating to their health and mobility.

We carried out a previous focused inspection of Willow House on 26 November 2015 and identified some concerns. These related to risks to people not always being identified and acted on, medicines not always being managed safely, people not always being treated with dignity and respect, records not always being accurate and systems in place to monitor the care provided not being effective. At this inspection in May 2016 we found the registered manager and the provider had worked hard to improve the service. A lot of improvements had been made and some of the issues previously identified had been rectified. However, we did identify some concerns that still needed addressing.

People were not safe from risks relating to the management of medicines. One person had one specific medicines hand written three times in their medicine administration record along with two different instructions which would have caused confusion for staff. Staff had not always recorded how many tablets people had been administered when these were variable. There was a lack of guidance in people’s care plans and in the home relating to PRN (when required) medicines used to treat anxiety and agitation. This could pose risks of people receiving medicines when they did not need them or not receive them when they did.

People’s records were not always accurate or up to date and were sometimes confusing. For example, staff had recorded three different weights for one person on their fluid intake records which changed the target amount of fluid they should be having. Another person had significant gaps in the recording of their regular repositioning in order to reduce the likelihood of damage to their skin. The processes and systems in place to monitor, assess and mitigate the risks to people had failed to identify the concerns we found during our inspection. Although audits and checks were in place these had not been effective in identifying issues and mitigating risks.

Where specific guidance had been sought from specialist professionals in relation to people’s eating and drinking, we found this guidance had not always been followed by staff. We made a recommendation that, where specialist advice was provided this was followed in order to ensure people were receiving care which followed best practice.

Following our inspection in November 2016 the service had signed up to an initiative called Dementia Care Matters which aims to improve the care home experience for people living with dementia. The registered manager, the directors and the staff spoke with obvious enthusiasm about the changes they were implementing at the home and how these were benefitting people.

Work had gone into improving the environment at Willow House and further work was planned. The atmosphere in the home was warm and welcoming and the home was decorated in a way that felt homely. Thought had gone into the layout of the living rooms and the dining room and changes had been made to enable people to move around independently where possible.

People were b

We carried out an unannounced comprehensive inspection of this service on 3, 4 and 5 March 2015. Breaches of legal requirements were found in relation to regulations 9, 13, 23, 20 and 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. These correspond to regulations 9, 12, 18, 17 and 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to people not receiving person centred care, people not receiving safe care and treatment, staff not being appropriately supervised and appraised, people’s records were not always being kept securely or located promptly and staff not always being trained in using suitable equipment.

After the comprehensive inspection, we asked the provider to write to us to say what they would do to meet legal requirements in relation to the breaches. The provider did not write to us but did take some steps to respond to the breaches.

After that inspection we received concerns relating to people’s care needs not being met, people’s safety with regard to bed rails and sensor mats, staff behaviours which did not show respect for people, people not always receiving their medicines as prescribed by their doctor, and people not drinking enough to maintain good health.

As a result we undertook this focused inspection to look into the concerns raised and to check the providers had taken sufficient action to meet their legal requirements. The report covers our findings in relation to those topics and those requirements.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Willow House on our website at www.cqc.org.uk

Willow House is a care home which provides accommodation and personal care for up to 30 older people. Some of which may have care needs related to their dementia. People who live at the home receive nursing care through the local community health teams. The home had not had a registered manager in post for six months but a manager had been appointed and was in the process of applying to be registered. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The inspection took place on 26 November 2015 and was unannounced. At the time of our inspection there were 28 people using the service. People had a range of needs, with some people being independent and others requiring more support with their mobility and care needs. A significant amount of people who lived in the home were living with dementia.

During this inspection we found action had not been taken by the provider to meet all their legal requirements. Some legal requirements breached at our previous inspection in March 2015 had been met but some had not. We also found new breaches of regulation and areas that required improvement.

People who lived at the home were not always safe. Sufficient action had not been taken to ensure legal requirements were met in relation to the management of medicines. We found inaccurate recording meant effective medicines audits could not be completed by staff. It was therefore not possible for staff to ensure people had received their medicines as prescribed by their doctor.

People were at risk of dehydration and sufficient steps had not been taken to prevent or rectify this. For example, one person had very low fluid intake and on two occasions only drank 250mls in a day. This person had not been referred to their doctor in relation to this low fluid intake and accurate records of their intake were not always kept. This meant staff were not able to accurately assess the person’s fluid intake or know how best to respond to it.

Risks to people had not always been identified and responded to. For example, one person had lost 19kg in one month and 2.5kg the following month. This person had not been referred to a doctor or a nutritionist. Their care plan and risk assessments had not been updated to reflect the weight loss or to direct staff on how to respond to it. Records of this person’s food intake were not regularly kept which meant staff were not able to accurately report on what they were eating and how to encourage them to eat more. The provider did not have a thorough understanding of the Mental Capacity Act 2005 (MCA) which meant they did not always follow the legal requirements with regards to gaining people’s consent or follow best interest guidelines. People were having their movements restricted unlawfully. Deprivation of Liberty Safeguards (DoLS) are applications to legally deprive people of their liberty under the MCA. In order to deprive people of their liberties, such as not being able to leave premises unescorted, it is necessary to have the legal authority to do so. The provider had applied for DoLS for every person living in Willow House. This included people who had full mental capacity and for whom the MCA did not apply. The manager told us that should a person who lived in Willow House and who had full mental capacity ask to leave unescorted this would be refused because they were fearful of their safety. It was explained to the manager that this was unlawful and they told us they would acquire further knowledge in this area.

Willow House did not have an environment which was adapted for people with dementia. This environment did not make it easy for people to find their way to their bedrooms or around the home. This did not show understanding for people’s diversities and the home’s environment did not suit people’s needs. The manager had not sought guidance around providing environments that were supportive of people living with dementia and the best practice to follow.

We have made a recommendation for the provider to research and implement guidance for supporting people with dementia in an enabling environment.

People were not always treated with kindness and respect. During our inspection we observed several negative interactions between staff and people. For example, one person was told to “sit down there and drink your coffee” in a tone that resembled telling off a child. One person said “Sometimes they can be a bit sharp because they’re overworked but in general they are very good to me”. The manager displayed kindness towards people and was working on ways to make people’s care plans reflect their personalities more. The provider had taken steps to ensure the culture at the home improved. There had been discussions with staff about culture during supervisions and staff meetings. There had also been a ban on staff taking cigarette breaks together. Further training had been sought in relation to culture and each member of staff had been provided with a staff handbook which highlighted culture.

At our previous inspection in March 2015 we found the provider was breaching their legal requirements in relation to unsafe techniques being used to move people. At this inspection we found appropriate techniques were being used and the provider had ensured all staff had received retraining in moving people safely.The provider had made changes to their quality assurance systems but these had failed to identify some of the concerns we found during this inspection. The provider had also failed to respond appropriately to some of the concerns and legal requirements identified during our inspection in March 2015. We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches relate to people not always being treated with dignity and respect, people not being protected from the unsafe management of medicines, risks to people not always being identified or responded to, legal requirements under the Mental Capacity Act 2005 not always being followed, records not always being accurate or up to date and quality assurance processes failing to effectively mitigate risks to people.

You can see what action we told the provider to take at the back of the full version of this report.

People we spoke with told us they were happy with the standard of care they received. One person said “I am very lucky. I get well fed, well looked after and don’t have to do anything if I don’t want to.” We spoke with a relative, and three health care professionals who were also happy with care at the home. They said communication was “excellent”.

People told us they were treated with respect and we witnessed this during our inspection.

Staff knew about recognising and preventing abuse. They had a good understanding of the different types of abuse and were able to correctly describe the procedure to be followed if they suspected or witnessed any. People told us they felt safe and that care workers were very caring. One person said “I watch what goes on. I have never seen the staff show anything but kindness.”

The feedback about staff from people who lived at the home, relatives and health care professionals was very good. Staff were described as being “kind”, “caring” and “delightful.” There was a stable staff team who cared for people at the home. People told us they thought there were enough staff on duty. Staff told us there had been some instability in the staffing but this had settled now leaving a “good team of staff.”

There was an effective system in operation which was designed to enable the provider to regularly assess and monitor the quality and safety of the services provided.

The inspection took place on the 3, 4 and 5 March 2015 and was unannounced.

We last inspected the service on the 29 January 2014 and found no concerns.

Willow House provides residential care without nursing to 30 older people. This could be for people living with dementia; with mental health needs and physical disabilities. There were 28 people resident in the service when we visited.

There was 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.

People were at risk as the administration of medicines was not safe. We identified issues in respect of the storage and accounting for people’s medicines. We requested the registered manager and provider took immediate action as none of the records could be relied on as accurate. New records were put in place and prescriptions requested by the registered manager where people may have had too few medicines available to meet their needs before the next ordering cycle. By the third day of inspection, people’s medicines records and stock of medicines were accurate, however it was too soon to ensure this would be maintained over time.

Risk assessments took place to identify how to support people to remain safe. This was for the risk of falls, of pressure ulcers and of malnutrition. However, people’s individual needs were not risk assessed or reviewed when their health or associated behaviour may place them or others at risk. When risk assessments were updated this was not always clearly linked with people’s care plans.

Prior to the inspection we had concerns raised with us that people were not being safely moved by staff. We were told by the provider this had been addressed. We reviewed manual handling during this inspection and found staff did not always move people safely. Staff who were not trained to move people safely were carrying out that role. This meant people may have been at risk of injury.

People gave us mixed comments of whether they thought the staff were caring and treated them with kindness and respect. People told us they had positive experiences of how staff treated them but other people stated they did not. Everyone we spoke with said staff respected their dignity and privacy. This was especially when personal care was being given. We observed staff did not always treat people and each other with respect. The registered manager and provider stated they would follow this up with staff immediately to ensure people received a caring response.

There were sufficient staff employed to meet people’s needs and staff were recruited safely. Staff understood the importance of keeping people safe from abuse. They demonstrated they knew how to identify and report concerns to management, the local authority or CQC. Staff felt any concerns would be responded to appropriately by management.

Staff underwent training to carry out their role however; they were not being supervised or appraised appropriately to ensure they were able to continue to deliver care safely. Where issues were identified with staff action was not always taken or recorded.

People were having their ability to consent to their care and treatment respected however the assessment of people’s capacity was not stored in people’s care records. The registered manager told us the assessments had taken place and were stored in a filing cabinet in the main office. However, these could not be located by the registered manager.

People said they were having their health needs met and were able to access a range of health care professionals as required. However, people who could not ask for a drink were at risk of dehydration as staff were not supporting people as required. Also, staff were not clearly recording how much people had drunk when required. Concerns were not being recognised or following up with relevant healthcare professionals. This was put right by the third day of the inspection. The recording and meeting people’s food intake was very clear and action was taken when this was causing a concern. People had their need for a balanced diet met and were happy about the quality of the food. People were given a choice of what to eat and when.

People had care plans in place which were personalised; however these required updating and did not always ensure all their needs were assessed. The care plans highlighted people’s preferences on how they would like their care delivered.

People said staff responded quickly to their call bells. We observed however, that not all people’s care needs were responded to during the inspection. For example, one person living with dementia was being left in a wheelchair without the required pressure relieving cushion for long periods. The registered manager advised this should not be the case as the person should be moved back to the easy chairs in the lounge to prevent pressure ulcers. Another person had to repeatedly ask for staff to take them to the toilet as staff did not respond when asked.

People were provided with activities and could go out on trips. People stated they were supported to follow their chosen faith.

People and their relatives told us they felt able to raise concerns or a formal complaint. Everyone and staff we spoke with identified they felt they could speak to the registered manager about any issues. The service’s complaint policy was made available to everyone. People’s complaints were investigated and action was taken to try and prevent this happening again for anyone else. People were involved in feeding back about the service via a third party organisation. We could see action was taken when people raised a concern and they were happy with the outcome of their complaint.

The service had a clear system of governance and leadership in place along with quality assurance processes, however this had not identified the issues raised during the inspection.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which correspond to regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have told the provider to take at the end of the full version of the report.