The Willows

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.

People and their representatives were involved in assessing and planning the care people required. Assessments of people’s care were thorough and captured important aspects of people’s lives and history. However, we could not be assured staff always followed people’s care plans, due to the concerns we identified during our inspection. The service worked with other health and social care professionals to ensure people received care which met their needs. We found the service was working within the principles of the Mental Capacity Act 2005 and if needed, appropriate legal authorisations were in place to deprive a person of their liberty.

Staff and leaders had developed positive relationships with people, which supported them to deliver person centred care. Care plans were holistic, and took people aspirations, goals and strengths into consideration. Family members told us they found staff to be caring and kind. We observed people to be relaxed in the company of the staff supporting them. Processes to support staff were in place, and opportunities to give feedback were plentiful. However, we identified some tensions between the staff team which the service told us they will work to improve.

People received person-centred care from staff who knew them well. The service worked in partnership with other agencies, and external support was requested as required. Peoples communication needs were assessed and resources were in place to aid staff to communicate with people in their preferred method. Processes to support the involvement of people in their care planning were effective. Staff were provided training to be able to recognise and protect people’s protected characteristics.

The provider was in breach of the legal regulation relating to good governance. The service had several overarching quality assurance processes in place, however these had not always been accurately completed. The registered manager had not identified that internal audits were consistently scoring full marks despite this being incorrect, therefore we were not assured their level of oversight was sufficient. We identified some evidence of a poor culture, which impacted communication between staff and leaders. Whilst some staff felt able to make use of the providers internal processes for raising concerns, others were fearful of repercussion and chose to speak with us anonymously. When things went wrong, processes designed to drive improvement had not always been effective, and as a result action had not been consistently taken in response.