We carried out an unannounced comprehensive inspection of Willow House on 9 and 13 December 2016.

Willow House is a care home providing accommodation and personal care for up to 18 older people. Most of the people using the service were living with dementia. When we visited there were 16 people using the service. The service is a converted residential dwelling with accommodation over two floors. People live in single or shared rooms and bathroom facilities are shared. There is a dining room and sitting room which is also used as an activity room.

The home had a registered manager in place. 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 service is required by a condition of its registration to have a registered manager.

Our previous inspection on 29 September and 16 October 2015 identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found the provider had taken action to address the concerns we had identified. Sufficient improvement had been made for the provider to meet the requirements of the two previously breached regulations in relation to good governance (Regulation 17) and requirements relating to workers (Regulation 19).

The provider had introduced new quality assurance systems and additional checks had been put in place to support the registered manager and staff to continually evaluate the quality of the service people received and risks in the home. We found these systems had been effective in driving improvements for example, in staff training and supervision and monitoring of health and safety requirements in the home.

The provider had improved their recruitment practices and we found all the required staff pre-employment checks had been completed to ensure staff would be suitable to work at the home.

People received their prescribed medicines safely and had access to healthcare services when they needed them. People liked the food and told us their preferences were catered for. People received the support they needed to eat and drink enough.

Staff had a good knowledge of their responsibilities for keeping people safe from abuse. Staff sought people's consent before they provided their care and support. Where people were unable to make certain decisions about their care the legal requirements of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS) were followed.

Care plans were based around the individual preferences of people as well as their medical needs. They gave a good level of detail for staff to know what support people required. Staff received training and supervision to support them to meet the individual needs of people effectively.

People were treated with kindness, compassion and respect and staff promoted people's independence and right to privacy. The staff were committed to enhancing people's lives and provided people with positive care experiences.

People knew how to make a complaint. People told us the manager and staff would do their best to put things right if they ever needed to complain.

The inspection was carried out by an adult social care inspector. At the time of our inspection 16 people were living in the home. A number of the people at Willow House were not able to communicate their experience of living in the home. To help us to understand the experiences of these people we used our SOFI (Short Observational Framework for Inspection) tool. The SOFI tool allowed us to spend time watching what was going on in the home and helped us to record how people spent their time, the type of support they got and whether they had positive experiences. In addition we spoke with four people who could tell us their experiences and the relative of one person

.

We also spoke with the registered manager, two health professionals, two care workers, one cleaning and one catering staff member. We looked at documents including care plans and management reports.

We considered information we held about the home to decide on the focus of the inspection. All of the evidence we had gathered under the outcomes we inspected was used to answer the five questions we always ask;

• Is the home caring?

• Is the home responsive?

• Is the home safe?

• Is the home effective?

• Is the home well led?

Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the home caring?

Overall we found that the home was caring. People told us that staff were caring and this was supported by the positive interactions with people we saw during the inspection. A relative told us that they were kept informed of their loved one’s care and welfare.

Is the home responsive?

The home was not always responsive. People’s care had not always been planned to ensure their welfare was maintained. Though staff could describe the action the home took to respond to people’s changing health needs including ensuring they ate and drank enough, these changes had not always been recorded in peoples care plans to ensure that people would receive the care they required.

A visiting health professional told us that the home contacted them promptly when people’s behaviour changed and implemented their guidance. However, this guidance had not been recorded in people’s care plans to ensure that staff would implement it consistently.

Is the home safe?

The home is not safe at this time. The home identified risks to people’s safety but records did not always provide staff with sufficient information to ensure that people were protected from the risk of falling or their behaviour harming them or others. The home was undertaking some maintenance to the lift and repairing the fire damage. The provider did not have written risk assessments in place to ensure that safety plans in relation to the maintenance work was robustly communicated with staff and the safety arrangements monitored.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DOLS) which applies to care homes like Willow House. The manager had an understanding of how the Mental Capacity Act (2005) and DoLS applied to people in the home and was working with the local authority to complete the required DoLS authorisations.

The home had undertaken a robust fire safety audit. A fire risk assessment and personal evacuation plans were in place to ensure the home managed the risk of fire appropriately.

Is the service effective?

The service was effective. The home was meeting people’s nutritional needs and was reviewing the number of staff over weekends to ensure that they maintained consistent quality of care across the whole week.

Is the service well led?

The service was not always well led. Though systems were in place to assess the quality and risks relating to the service, records were not always kept to support the registered manager to monitor the home’s compliance with legal and professional guidance for example in relation to falls and recruitment.

A number of people who use the service had advanced dementia and were not able to verbally communicate with us, or had very limited ability to do so. Therefore we spent time looking at care records and talking to representatives of people who use the service. We talked to staff and observed interactions with the people using the service to determine how their needs were being met and to understand their individual experience of the service.

The people who use the service who could communicate with us told us that they were well looked after and that the staff were very caring and understood their needs well. Representatives of people who use the service told that the home was always clean and tidy and that they could visit their relative at any time. One representative told us that they visited their relative several times a week and that the provider always made them feel welcome. One representative told us “my relative is well cared for and is very happy”.

We looked at the care records of seven people using the service. We found the records to contain details about the person’s likes and dislikes, their personal and medical history and next of kin. However we found that the assessments and reviews were inconsistently completed and did not include appropriate information in relation to the care and treatment being provided to people using the service.

The staff we spoke with had a good understanding of adult safeguarding and understood their role and responsibilities in the safeguarding of adults at risk of harm. The staff we spoke with knew how to raise concerns and how to reduce risk of harm occurring.

On the day of our inspection we found there to be sufficient number of staff on duty. We found the staff to be supportive and caring of all of the people and they had a good understanding of their care and support needs. We observed the staff and their interaction with people and saw them arranged activities to suit each person’s needs. Staff had received the appropriate training to support the people, many of who could not verbally communicate their wishes.

We spoke with representatives of people who use the service and they were satisfied with the care being provided to their relatives. One representative told us “the staff are very approachable and know how to care for people with dementia”. Another representative told us “my relative can be very challenging and repetitive and the staff deal with it very well”.

All of the areas of the home that we looked at were clean and tidy. The kitchen was well organised and medication was secure. The representatives we spoke with all said that the home was always kept clean and tidy. One representative complimented the housekeepers saying “the rooms are always kept lovely and clean”

The majority of the people at Willow House had dementia and were unable able to tell us about their experiences in a meaningful way. To help us to understand the experiences of people have we used our SOFI (Short Observational Framework for Inspection) tool. The SOFI tool enabled us to spend time watching what was going on in the service and helped us to record how people spent their time, the type of support they got and whether they had positive experiences. We spent most of our time observing care and found that people had positive experiences.

People who could express a view told us the staff were lovely. One said "They were very kind and caring", another person said "The manager is good, she keeps the staff on their toes". Relatives spoken with told us the care provided at the home was good and their relatives were well looked after. One said "My Mum is really happy here and she is well cared for".

People received safe and coordinated care, where more than one provider was involved.

People were treated respectfully and their views were taken in to account by staff. Staff understood the signs of abuse and were confident about raising their concerns with the appropriate people.

People's health and welfare needs were met by sufficient numbers of appropriate staff.

People who could express a view told us if they were not happy they would tell someone. One person said "If I wasn't getting looked after properly they would soon know about it".

A number of the residents at Willow House had dementia and therefore not everyone was able to tell us about their experiences. To help us to understand the experiences of people have we used our SOFI (Short Observational Framework for Inspection) tool. The SOFI tool allows us to spend time watching what is going on in a service and helps us to record how people spend their time, the type of support they get and whether they have positive experiences.

Staff were observed to have a good rapport with people, encouraging them to join in with the activity 'A right Royal Occasion'. We observed that the majority of people were happy to take part in the activity, and enjoyed the experience, several of them joined in with the singing. We observed support being offered in a discrete and sensitive manner and all of the people responded positively to this.

People who could express a view told us they were very happy at the home. They said that the staff were helpful and looked after them well.

Relatives informed us that they were consulted about their relative’s care needs, as and when appropriate. They told us they felt able to raise any complaints and they were confident that there concerns would be responded to and dealt with quickly.

People told us the manager was always around to help them.

A number of the residents at Willow House had dementia and therefore not everyone was able to tell us about their experiences. To help us to understand the experiences of people have we used our SOFI (Short Observational Framework for Inspection) tool. The SOFI tool allows us to spend time watching what is going on in a service and helps us to record how people spend their time, the type of support they get and whether they have positive experiences.

Residents who could express a view told us they were very happy at the home. They said that the staff were "kind" and " helpful.

They told us their bedrooms were kept clean and tidy.

Relatives told us that there had been problems in the past but that they were now happy with the care provided at the home. They told us they believed their relatives were safe living at the home.

Relatives told us they felt able to raise any complaints and that they would be responded to and dealt with.

We carried out an unannounced comprehensive inspection of Willow House on 29 September and 16 October 2015.

Willow House is a care home providing accommodation and personal care for up to 18 older people. Most of the people using the service were living with dementia. When we visited there were 18 people using the service. The service is a converted residential dwelling with accommodation over two floors. People live in single or shared rooms and bathroom facilities are shared. There is a dining room and sitting room which is also used as an activity room.

The manager was registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC 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.

We previously inspected the service in January 2015 and found several regulatory breaches. During this inspection we checked whether the provider had taken action to address the concerns we found. We found the provider had made many of the required improvements, however some time was still needed to ensure all of these improvements were fully implemented, sustained and firmly established as part of the service’s routine way of working.

The registered manager of the service was well liked and knew people and the staff at the service well. People and relatives found her easy to talk to. People felt safe at this service and told us they got the right support from staff. The training staff received had developed their understanding and confidence in meeting people’s health needs. Regular supervision had been introduced but these needed to be better documented so that staff could refer to a record of discussions to understand how they needed to develop their skills to meet their role effectively.

People received their prescribed medicines safely and had access to healthcare services promptly when required. People liked the food and told us their preferences were catered for. Improvements had been made to the layout of the home and this had given people more choice about where they wanted to spend their time and eat their meals. Improvements had been made in the support people received from staff to participate and get involved with the activities on offer. The registered manager was still working with people to create opportunities for everyone to do the things they enjoyed.

Staff knew how to keep people safe. Staff had received training in safeguarding and were able to demonstrate an awareness of abuse and how concerns should be reported. People were treated with kindness, compassion and respect and staff promoted people’s independence and right to privacy. The staff were committed to enhancing people’s lives and providing people with positive care experiences.

Staff sought people’s consent before they provided their care and support. Where people were unable to make certain decisions about their care the legal requirements of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS) were followed. Where people had restrictions placed upon them to keep them safe, the staff continued to ensure people’s care preferences were respected and met in the least restrictive way.

Some people were not capable of clearly expressing their opinions and the provider had started to find ways of capturing and responding to their views. The provider had made improvements to the care planning process to ensure people’s risks were effectively managed and their health needs addressed. The quality of management and care records kept in the service had improved. However, all the required information was still not available in staff employment records and people’s care records did not reflect all the care they received or required.

The provider had improved the systems to assess, monitor and improve the service. The registered manager was developing a comprehensive systematic oversight of the service and was aware of feedback from people and their relatives. There were new systems of monitoring and auditing and the registered manager was still working to effectively establish these at the service.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.