Archived: Willows Nursing Home

Updated 1 June 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This comprehensive inspection took place on 8 and 11 May 2018. The inspection was unannounced. The inspection team consisted of two adult social care inspectors.

Before the inspection the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and any improvements they plan to make. We checked the information that we held about the service and the service provider including any feedback we had from commissioners of the service such as social services. This included statutory notifications sent to us by the provider about incidents and events that had occurred at the service. A notification is information about important events which the service is required to send to us by law. We used all of this information to plan how the inspection should be conducted.

We spoke with seven people who were living at the service, a visiting health care professional, 14 staff including the manager, nursing staff and senior managers.

We spent time looking at records, including four care records, two staff files, medication administration record (MAR) sheets, staff training plans, complaints and other records relating to the management of the service.

Updated 1 June 2018

Willows Nursing Home 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.

The home has been converted from a large three storey house close the centre of Birkdale, near Southport. The home can accommodate up to 28 people with a variety of nursing needs. There were 21 people in residence at the time of the inspection.

This was an unannounced inspection and it took place on 8 and 11 May 2018.

At the last comprehensive inspection in April 2017 we found a breach of regulations with in respect to, induction and training standards for new staff and medicines management. The service was rated as ‘Requires improvement’. We followed this up in September 2017 to review the breaches of regulations we found improvements and the breaches had been met. We did not review the overall quality rating at that time and the home remained ‘Requires improvement’.

On this inspection we found improvements had been sustained and the home had continued to develop. On this inspection we rated the service as ‘Good’.

A manager was in post who was in the process of becoming registered with the Care Quality Commission. 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. The manager had previous experience of working at senior level with the registered provider.

Potential risks to people using the service were clearly identified. Effective care plans had been agreed with people so that potential risks could be reduced.

Medicines were safely stored and administered in accordance with best-practice and people’s individual preferences. Nursing staff were updated and trained in administration. The records indicated that medicines were administered correctly and were subject to regular audit.

Key documentation included attention to ensuring peoples consent to any care and treatment was recorded and operated in accordance with the principles of the Mental Capacity Act 2005 (MCA).

The Willows had improved much of their key assessment and care planning documentation and it was now clear and detailed regarding peoples care. People’s needs were assessed and recorded by suitably qualified and experienced staff. Care and support were delivered in line with current legislation and best-practice.

The service had continued to develop quality monitoring processes and the manager had support from senior managers in the organisation.

Policies and procedures provided guidance to staff regarding expectations and performance. These included policies regarding equality and diversity. Staff were clear about the need to support people’s rights and needs and recognised individual needs. Care records contained information about people’s sexuality, ethnicity, gender and other protected characteristics. We discussed ways during feedback how this area could be developed further; this included attention to developing the visible cues in the environment to accommodate people living with dementia.

People using the service and staff were involved in discussions about the service and were asked to share their views. This was achieved through daily contact by the managers and staff and regular surveys and meetings. These provided very positive responses regarding people's care.

Overall the service maintained effective systems to safeguard people from abuse and the service had worked effectively with the local safeguarding team when needed.

We saw evidence that the service learned from incidents and issues identified during audits. Records showed evidence of review by senior managers.

The service ensured that staff received induction training. Training was subject to regular review and continued to develop to ensure that staff were equipped to provide safe, effective care and support.

We saw clear evidence of staff working effectively to deliver positive outcomes for people. People reviewed were receiving effective care and gave positive feedback regarding staff support.

We saw evidence that the service worked effectively with other health and social care agencies to achieve better outcomes for people and improve quality and safety. We spoke with professional staff that contracted with the service for rehabilitation of people from hospital. We were told that the service offered effective care which met people’s needs.

People told us that staff treated them with kindness and respect. It was clear from care and incident records that staff were vigilant in monitoring people’s moods and behaviours and provided care in accordance with people’s needs.

We checked the records in relation to concerns and complaints. The complaints’ process was understood by the people that we spoke with. We saw evidence that complaints had been responded to in a professional and timely manner by the registered manager or a senior manager.

People spoke positively about the management of the service and the approachability of senior staff. There was clear management structure that supported staff and which people understood.