The Willows Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable

harm. At our last assessment we rated this key question good. At this assessment the rating has

remained good: This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty.

Staff listened to concerns about safety and investigated and reported safety events. Lessons

were learnt to continually identify and embed good practice. For example, the provider had a

system in place to monitor safety events in real time and track any required actions. Lessons

learned were shared within the service and more widely across the organisation.

The provider worked with people and healthcare partners to establish and maintain safe

systems of care, in which safety was managed or monitored. They made sure there was

continuity of care, including when people moved between different services. We saw evidence

of appropriate referrals, for example, to speech and language therapy and dietitians where this

was required.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. Staff were aware of their responsibilities to keep people safe, knew who they could report concerns to externally if they needed to and told us they would not hesitate to raise any concerns. One relative said, “They are good people and I know [Person] is safe in their hands.”

The provider worked with people to understand and manage risks by thinking holistically. Staff

provided care to meet people’s needs that was safe. Care plans outlined areas of risk and

measures in place to mitigate them. The provider took a proportionate approach to risk and

regularly reviewed these plans with people and their relatives. People and relatives told us they

felt safe in the service.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. We saw equipment was serviced regularly. The environment was free from any health and safety concerns. However, we did note some rooms had a malodour. The provider told us there were already plans in place to replace carpets to improve this.

The provider did not always make sure there were enough qualified, skilled and experienced

staff. Whilst we observed there were enough staff to keep people safe, there was often limited

time for staff to spend with people outside of care tasks. The provider told us a newly introduced

care planning system which was contributing to delays. To immediately improve this, they added

an extra staff member to support the transition. Feedback from people and relatives about

staffing was mixed with comments such as, “There seems plenty [of staff]”, “There are enough

staff on the day shift when I visit” and “I wonder whether there’s enough staff giving [person] any

time. Meals are brought but they don’t eat, I’m not sure [staff] have the time to sit and encourage

them”, “I think they are short staffed at the moment” and “I don’t think there’s enough staff.”

The provider assessed and managed the risk of infection. They detected and controlled the risk

of it spreading and shared concerns with appropriate agencies promptly. The environment was

clean. We observed staff washing their hands and wearing appropriate personal protective

equipment when supporting people.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Systems were in place to safely administer and store medicines. Medicines records we reviewed demonstrated that people were receiving their regular medicines safely. Care plans had comprehensive information about people’s medicines. Medicines used ‘when required’ (PRN) to alleviate anxiety or pain were used infrequently. Guidance in the form of PRN protocols were in place but could be improved to ensure they were always person-centred. Staff administering medicines had completed medicines training and had a competency assessment documented.