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

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 inadequate. At this assessment the rating has remained inadequate. This meant people were not protected from avoidable harm.

At our last assessment we found breaches in regulations relating to safeguarding, staffing and safe care and treatment. We served a warning notice for Regulation 12: Safe care and treatment and Regulation 18: Staffing. At this assessment, we found some improvements had been made in relation to safeguarding and they were no longer in breach of regulation, but this was ongoing and not yet fully embedded. Enough improvement had been made relating to staffing and the provider was no longer in breach of regulation in this area. We found the provider had not met the legal requirements relating to safe care and treatment, therefore this is a repeated breach of Regulation 12. The provider did not have effective systems in place to assess and manage risks to keep people save from avoidable harm. The systems for monitoring safety were not robust to recognise and address safety concerns. Lessons were not learned and used to drive improvement.

This service scored 34 (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 did not have a proactive and positive culture of safety. They did not have a robust system to analyse concerns about safety and use them to drive improvement. Lessons were not learnt to drive improvement and continually identify and embed good practice.

There was little documented evidence to demonstrate lessons were learned and disseminated to staff to reduce future risks. The manager told us they had an informal system of learning lessons, which were shared with staff. We reviewed the record for complaints, safeguarding and analysis of incidents and accidents, none identified how lessons were learned and used to drive improvement in the service. For example, where a person had repeated unwitnessed falls in November and December 2024.

The provider had not made the necessary improvements in the service since our last assessment, to ensure people using the service received safe care at all times. This does not demonstrate a learning culture within the service at provider and management level. We were not assured the provider had robust systems to independently identify risks and poor outcomes and address them.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

A member of staff told us, if for example, a person was admitted to hospital, other professionals were provided with information about their medicines and a verbal overview of the person. They were considering documentation to include important information about each person, but this had not yet been formulated. Treatment people had received was not always documented. For example, a staff member told us a person had received surgery, but their care plan stated they were due to have surgery. Another person’s care plan and risk assessments held contradictory information about the support they required with their continence needs. We found care plans and risk assessments had not been kept up to date to show people’s current needs, such as contradictory information relating to the support a person required with their continence. This was a risk that inaccurate information could be passed to other professionals should a person require to move between services, such as hospital admission.

Two people’s relatives told us, prior to their family members moving into the service, an assessment of need was undertaken and they, and their family members were consulted. Needs assessments were used to inform the care plans and risk assessments. However, other relatives told us they had not been given the opportunity to review their family member’s care plan with staff to ensure it reflected their family member’s needs and preferences and to suggest changes. There was no evidence provided to show people were consulted in their ongoing care.

The provider did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Since the last inspection, there were more staff available to reduce the risks of people entering other people’s bedrooms uninvited and some people who did this no longer lived in the service. However, a person told us this still happened. The person told us they locked their bedroom door to prevent other people entering and another person’s relative said people still went into their family member’s bedroom. A person’s care records stated they were to be monitored when they walked with purpose to reduce the risks of accessing other’s personal space, however, during our visits, we saw this person walking in the corridors with no staff present. The daily notes reviewed, showed that on the middle floor at the care home, people had entered other people’s bedrooms, when this was not wanted. There was no analysis to identify potential patterns and to proactively manage the risk.

Safeguarding concerns were raised with professionals responsible for investigating concerns of abuse. However, we were told of an instance when full information had not been provided to the safeguarding team when a referral had been made. Stakeholders told us when improvements had been made to improve people’s safety, these were not sustained and embedded in practice. Records of safeguarding did not always include information about if they had been substantiated or not. There was no analysis to identify potential trends and lessons learned to prevent future incidents. We had not been formally notified of incidents which had been raised externally. The manager told us this was an oversight and immediately sent the notifications to us.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Since our last assessment, there had been some improvements in how risks were being assessed and mitigated. However, there were still risks which had not been assessed and measures in place to guide staff in how to keep people safe from harm. There were still contradictions and omissions in people’s care records. For example, a person’s falls risk assessment included the risks such as the medicines they took which increased their risk of falls, however, there was no guidance in how the risks were being mitigated.

Where people were assessed at risk of pressure ulcers and required support and or prompting to move position, daily notes did not evidence people were supported in line with the timeframe given in the care plans. A person’s care plan stated they required the use of a pressure cushion to reduce risks, however, we saw them sitting in the shared areas without the cushion. This placed people at risk of acquiring pressure ulcers.

Although information was provided to the catering staff on what textures of food people required, there was no list of people provided of the people at risk of choking. In addition, we saw some people were provided with snack boxes, which a staff member told us were given to people at risk of losing weight and those who required a diabetic diet. The contents of these boxes included chunks of cheese and halved grapes which had the peel on, both of which were a choking risk. The manager told us they would review the contents of the snack boxes and if these were being provided to the people who were assessed as at risk of choking to ensure any choking risks were and mitigated.

The provider did not always detect and control potential risks in the care environment.

We saw there were some trip hazards in people’s bedrooms, such as call bell leads and sensor mat leads. We pointed this out to the manager who told us they would consider what actions could be taken. There were no risk assessments in people’s records relating to these risks.

The service was well-maintained throughout. Health and safety checks including fire and moving and handling equipment were undertaken to reduce risks to people.

Since our last assessment, the second floor of the service was no longer used to accommodate people. Some bedroom doors included items such as personal photographs or points of interest, which assisted people to independently find their bedroom.

The service used CCTV in corridors and externally, we saw notices were posted in the service, to advise people that CCTV was in use. Capacity assessments were in place for people relating to the use of the equipment.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. Staff did not always work together well to provide safe care that met people’s individual needs.

Since our last assessment where we were concerned about insufficient staffing levels, the provider had introduced a new dependency tool which was compatible with the electronic care planning system, to help assess the number of staff needed to meet people’s needs safely. The manager told us the dependency tool demonstrated the care staffing numbers were sufficient, despite them remaining the same as the previous assessment, when there were more people using the service. The manager told us agency staff were being used to cover vacancies until permanent staff could be recruited.

We received feedback from people using the service, relatives and staff how they felt the staffing levels had improved. Staff told us they felt the staffing levels were currently okay, but a staff member told us they were worried because they had heard cuts would be made. The manager informed us that the activity staff member had left the service prior to our assessment and active recruitment was taking place. This had left a gap in activity provision at the service.

At our last assessment we found shortfalls in the staff recruitment files. At this assessment, we found a staff member’s file did not include their recruitment records; these were sent to us during our assessment.

Improvements had been made in staff training, staff competencies and 1 to 1 supervision. However, we were not assured these were always effective due to the shortfalls identified at this assessment.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of cross contamination.

We observed a person eating their lunch and they had unclean fingernails, this was despite their care plan stating the staff were to check and clean their nails regularly. There were records to say their nails had been checked, but not in line with the frequency identified in the care plan, in addition, where records stated the person’s nails were checked they did not always show they were being supported to clean them. We also noted other people who had unclean nails, 1 was eating their breakfast. This did not support good infection control processes.

The service was visibly clean and hygienic throughout. The housekeeping team undertook audits and monitoring to reduce the risks of cross infection. A recent infection control audit was undertaken by external professionals and actions recommended were being addressed. The head housekeeper was the infection control lead and had started attending infection control meetings with health professionals. They told us how they were incorporating their learning into the service’s infection control processes. We saw personal protective equipment such as gloves and aprons were accessible to staff and they were using them as required.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

People who needed support with topical medicines, such as barrier creams to reduce the risks of pressure damage, were not receiving these as required. There were stock counts of these medicines, but no formal audits to monitor people were receiving them. Daily notes showed people were not always receiving their creams, for example, a person’s care plan stated they required creams to be administered before supporting them with a clean continence pad, however, their daily notes showed they were not always supported with their cream despite being supported to change their pad. Another person’s care plan said they also required cream to be administered, for 20 days, they only received their cream 3 days, on 19 days there was no mention of creams and on 3 days it stated no cream was available. These shortfalls placed the person at risk of skin injury. A member of the management team told us this had been identified but swift actions had not been taken. The management team were planning to move the ways the administration of creams was recorded to the electronic medicine system rather than the current daily notes. However, this was not in place at the time of this assessment.

Medicines were stored safely and regular temperature checks were undertaken in the refrigerator and medicine storage rooms. Medicines that were prescribed to be given orally or through patches were managed safely and regular monitoring checks supported the management team to quickly identify and address shortfalls. Staff responsible to administering medicines were trained and their competency was frequently checked.