The Willows

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

The provider was in breach of the legal regulation relating to safe care and treatment. Some improvements were required in relation to managing risks associated with peoples care needs. Whilst robust risk assessments were in place, we were not assured these were being followed due to concerns we found during our assessment. The environment was not always safe, and we found some people had access to items identified as potentially causing them harm. The environment was not always clean and well maintained. Medicines were administered as intended by the prescriber, and action was taken when discrepancies were identified. Staff were safely recruited and received appropriate training.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Overall, peoples relatives told us they felt lessons were learnt from incidents. One person told us ‘As [relatives name] has challenging behaviour, [they] can have an accident, [staff] do their best to prevent that, she’s safe at The Willows’. Another relative told us they were not sure of the process for learning lessons from incidents, but had confidence in the service to keep their family member safe.

We received mixed feedback from staff and leaders around the learning culture of the service. Some staff told us incidents were learnt from to avoid recurrence. However, others felt incidents and safety events were not acted upon thoroughly. The management team told us all incidents and accidents were thoroughly investigated and provided evidence in support of this. However, we were not assured that lessons had always truly been learnt, as we identified concerns of a similar nature to a recent incident during our assessment. Improvements are required to the process of learning from incidents and safety events.

Incidents and safety events were discussed and reflected upon in risk and governance meetings both at the service and with senior leaders. The management team told us meeting minutes were shared with staff to encourage practice development. Some staff appeared to be unaware of this process, and the provider told us they will work to ensure all staff are familiar with how incidents are acted upon and learnt from

Relative’s told us their loved ones move to The Willows had been positive. One persons relative told us ‘I don’t worry about relative’s name anymore, where she is,[The Willows] is a breath of fresh air.’ Relative’s spoke highly of how the service worked with other professionals to ensure the safety of their family member.

Staff and leaders told us they supported people to settle into The Willows by getting to know them well. The registered manager told us each person has a staff key worker who plays an important role in supporting a smooth transition. Some people living at the service had moved from different services, and the manager spoke passionately of how they have experienced positive changes since living at the service.

We did not receive any feedback specific to safe systems, pathways and transitions.

The service worked in partnership with other stakeholders to ensure people received the care they needed. Processes were in place to share information with other agencies appropriately. This meant risks associated with people's care could be shared easily to maintain people's safety across services.

Relatives we spoke with believed their family member was safe living at the service. One relative told us “Yes they can keep [relatives name] safe, they are proactive and reactive.” Another relative told us they felt more confident in the service due to increased staff training. They told us “Staff now are provided with tools to keep [relative’s name] safe.”

All staff we spoke with were aware of their responsibility to safeguard people, and could describe the procedures in place in the event of a safeguarding concern. Incidents of a safeguarding nature were investigated and analysed by the registered manager.

However, staff gave mixed feedback on whether they felt the service to be safe. Whilst most staff said they felt people living at The Willows were safeguarded, some felt action was not taken quickly enough by leaders in response to incidents of a safeguarding nature.

The people we observed were supported by staff and appeared relaxed in their company. One person we spoke with told us they were happy. We observed people in both their own bedrooms and communal areas. People were not restricted in their movement around the home during the day, or how they spent their time. Some people’s bedroom doors were locked overnight. For people who did not have the mental capacity to consent to some restrictions, including locked doors, the provider had made applications for Deprivation of Liberty Safeguards.

Systems and processes were in place for staff to raise concerns of a safeguarding nature. All staff we spoke with were aware of the process for reporting and escalating concerns both within and external to the service. There were multiple systems in place for staff to report concerns. Most staff felt confident to utilise these processes when necessary. However, we received feedback from a small number of staff who said they would not feel confident to raise safeguarding concerns to the management team. We asked the service to investigate the reasons why some staff felt unable to raise concerns to them directly. The service took action in response to our feedback.

Most relatives we spoke with felt risks were well managed. One relative told us “Yes [relative’s name] has been there for years and they understand risks for [relative’s name]. When out and about [they have] always been safe". However, another relative felt that whilst some improvements to risk management had been made with the introduction of electronic care records, communication needed to be stronger to ensure all staff were aware of risks associated with people’s care'. They told us they had reported an issue for staff to be aware of which may cause their loved one to become very distressed should it reoccur. When the issue reoccurred, staff were not aware of the family members report, and therefore did not know how to mitigate the risk of the persons behaviour escalating. The person was restrained to keep themselves and others safe, however the persons relative felt this escalation could have been avoided through improved communication.

The registered manager spoke passionately about wanting to support people living at the service to lead fulfilling lives, and was working with staff to help them further understand positive risk taking.

We received mixed feedback from staff in relation to risk management. Whilst most staff felt people were safe, others felt that risks were not always managed in a thorough and timely way. Staff we spoke with were not always clear on the risks associated with peoples care needs. For example, where one person had been identified as being at risk of ingesting non-edible items, their allocated staff member had not taken action when we identified a significant amount of risk items accessible in their bathroom.

We undertook observations to ensure care records were reflective of the care people receive. For one person with a history of self-injurious behaviour, their care plan stated they were at high risk of harm by ligature. However, when we observed the persons bedroom, we found trailing wires on the wall. We spoke with the staff members allocated to care for this person who were not familiar with the persons history, nor where to find ligature cutters in the event of an emergency as stated within the persons care plan.

Processes for identifying and managing risk were not robust. For one person with a history of ingesting a balloon, we found significant amounts of disposable gloves freely accessible within their bathroom. Whilst the person had a 1:1 carer with them during the day, staff told us the person was alone at nighttime and during handovers. This meant the person could ingest risk items without staff knowledge.

We found a radiator within another person’s en-suite bathroom to be excessively hot. The radiator was positioned very close to the toilet and was not covered. This risk had not been mitigated in a timely way. The registered manager reviewed these risks and took action in response to our assessment feedback.

People were not always supported to maintain a safe and clean environment. We observed several floors within people’s bedrooms to be in a poor condition, and requiring replacement. On our first site visit, the registered manager told us these floors were booked to be replaced that week. However, when we returned for our second site visit, the floors had not been replaced. The provider told us there had been difficulties with being able to access people’s rooms to undertake this work. One person we spoke with told us they liked their bedroom and spending time within it. Their room was personalised with their own artwork and favourite items

The registered manager acknowledged the issues we found, and confirmed works had been completed, or were booked in to be completed, by the time our assessment ended.

They also told us that whilst remedial work was needed to peoples bedrooms and the communal areas, they were not always able to undertake this as quickly as they would like due to contractor and material availability and the age of the building.

We observed parts of the environment, including peoples bedrooms and communal spaces, to be poorly maintained and unclean. We also found fire doors with compromised integrity, meaning they would not be effective at controlling the spread of fire. This meant people were not always living in a safe environment. Some people’s bedroom and bathroom floors were damaged and coming away from the wall and edges of the room. In another persons bedroom, we saw their window catch to be broken so the window was unable to be closed, and their bathroom to be dirty with mould and limescale build up. The registered manager told us in response to our findings they have a schedule of works in place, however could not always increase the speed at which work would be undertaken.

The provider had a schedule of works in place for the service. However, some items such as broken bath tiles, broken radiator covers and unsafe flooring required immediate attention to ensure peoples safety. We observed several floors to be so damaged they could not be effectively cleaned. We found a bathroom with broken tiles which the registered manager confirmed was still in use. We found radiator covers in place for peoples safety to be broken, which the provider told us they had already identified. We asked the provider to take action to mitigate these risks.

We received mixed feedback about staffing levels. Whilst all relatives we spoke with said they found there to be enough staff on duty during the day, some felt staffing levels overnight were too low. One relative said “[At night] they have three staff in the bungalow for ten people, if all goes well it’s fine, staff are dotted along the unit, when things go wrong never enough staff.” Another relative told us “[People] are ready for bed at 8.30pm as night staff can’t get them ready.” We asked the provider to review their staffing levels overnight in response to relatives feedback

We received mixed feedback from staff about staffing levels. All staff we spoke with felt there were enough staff on duty during the day. However, one member of night staff told us they felt staffing levels were sufficient under normal circumstances but expressed concern that additional staff would be needed overnight to safely manage unforeseen incidents. When we attended the service out of hours, another night staff member told us they were also responsibly for laundry and cleaning duties, making the shifts very busy.

The registered manager and provider told us they felt staffing levels, including overnight, were appropriate and had recently increased night staff numbers in response to simulated night time fire evacuation drills.

We observed staffing levels both during the day and at night. In communal areas and peoples bedrooms we could see there were enough staff to meet peoples needs during the day. Staff appeared relaxed and did not rush. However, we had concerns there would not be enough staff on shift at night in the event of an emergency. Whilst our observations showed there were enough staff on shift, the staffing levels were not reflective of normal practice due to additional staff being on site in response to our inspection visit.

Staff were recruited through robust processes. Staff also underwent a Disclosure and Barring Service check prior to starting work. This helped ensure the provider employed only staff suitable to work in this type of service. Staff had completed training in line with their role which was up to date. Staffing levels were monitored and reviewed by the registered manager, and changes made where necessary. We asked the provider to review their night time staffing numbers in response to feedback we had received, however they felt assured with the current staffing levels overnight.

Most relatives we spoke with said they felt the service was kept as clean and well maintained as possible, despite the challenges associated with people’s complex needs and behaviours. However, we found people to not always be living in an environment which was clean. One relative told us they had raised a concern regarding the cleanliness of their loved ones room. They told us they reported this several times before the issue was rectified, but felt the improvements had now been maintained.

We fed back the concerns identified regarding cleanliness and maintenance to the registered manager at the time of our site visit. They showed us audits completed by the staff team. They told us the items we had identified were already on a schedule of works, and therefore staff had been told not to acknowledge them on subsequent audits to avoid duplication. However, this meant audits undertaken by staff, scoring at full compliance, were an inaccurate reflection of the cleanliness of the environment.

Our observations found concerns with the cleanliness of the environment. This included heavy limescale build up on floors and in sinks, mould and damp patches, and areas so damaged they were not able to be cleaned effectively. This placed people are risk of harm through bacteria harbouring on unclean surfaces which could not be cleaned due to the poor condition they were in.

The provider had systems and processes to complete environmental checks and health and safety audits. These checks were completed both by staff at the service and by the providers health and safety team. However, checks undertaken at the service had not been effective in identifying the concerns we found during our assessment. We saw these audits were regularly scored by the staff members as the highest score even though there was evidence some concerns had been ongoing for a while.

People’s relatives told us that as far as they were aware medicines were well managed and administered as prescribed. When asked whether they felt their loved one received medicines as they should be administered, one person’s relative told us “As far as I’m aware, I don’t often see them”. Another relative was very confident in the service to administer medicines safely, and said “They are very good about it. Yes, never failed.”

The service had recently transitioned to an electronic medicine recording system. There had been some difficulties in doing so. Whilst we found some minor discrepancies in record keeping on our first site visit, our second site visit saw these to have been resolved. We discussed the concerns found with the registered manager at the end of our first site visit. The registered manager acknowledged there had been some ‘teething issues’ and agreed to undertake a full audit in response to our findings.

Policies and processes were in place to support the safe administration of medicines. However, we were given conflicting information regarding the auditing processes in place at the service. The registered manager initially told us additional auditing was being undertaken on a daily basis whilst a transition to a new system was underway. However, these audits were not shared with us. Whilst some audits were shared with us, these had been undertaken weekly, and were not reflective of the issues we had identified during our site visit. Daily auditing would have minimised the time taken to identify discrepancies in medicine records.