This inspection took place on 14 May 2018. The inspection was unannounced.

Willow Tree Nursing Home is a care home registered to provide nursing care and accommodation for a maximum of 47 people. People in care homes receive accommodation and personal care as a 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 is located in a residential part of Hillmorton in Rugby and most of the bedrooms are on the ground floor. There are seven bedrooms on the first floor. There were 38 people living at the home at the time of our visit, some of who were living with dementia.

We last inspected Willow Tree Nursing Home in February 2017 when we rated the service as 'Requires Improvement’ in the key questions of safe, responsive and well-led. We found medicines were not always managed safely, care plans were not personalised and quality monitoring checks were not effective. This meant the overall rating of the service was ‘Requires Improvement'. At this inspection we found improvements had been made and although further improvements were required in medicines management and infection control, the service is now rated as ‘Good’ overall.

The service had a registered manager. This is a requirement of the provider's registration. 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.

People felt safe living at Willow Tree Nursing Home and with the staff who provided their care and treatment. There were enough suitably skilled and experienced staff on duty to meet people’s care and support needs safely and effectively. The provider checked staff’s suitability for their role during the recruitment process and gave them training and support relevant to their position and responsibilities.

People’s needs were assessed before they moved to the home to ensure they could be met. Staff monitored people and were responsive to fluctuations in people’s health so they could be promptly referred to other healthcare professionals. People were supported at the end of their life in the home and staff worked with other healthcare professionals to ensure people had a dignified and pain free death.

Overall, people received their medicines as prescribed, but improvements were required to ensure best practice was always followed in the management of medicines.

The registered manager assessed risks to people’s health and welfare and wrote care plans that minimised the identified risks. Accidents, incidents and falls were investigated and actions taken to minimise the risks of a re-occurrence. Staff understood their role in keeping people safe and their duty to report any concerns that could compromise people’s safety.

The premises and equipment were checked and maintained to ensure risks to people’s safety were minimised. Generally, the environment was clean and tidy, but some infection control practices needed to be improved.

Managers and staff had a good understanding of the Mental Capacity Act 2005 and how to put this into practice. Where people required restrictions on their liberty to keep them safe from harm, Deprivation of Liberty Safeguards had been applied for and authorised.

People were encouraged and supported to eat and drink enough to maintain their health.

Care was planned to meet people’s individual needs and abilities and care plans were regularly reviewed and updated when people’s needs changed. The provider was committed to equal opportunities and diversity and people’s cultural, spiritual and religious beliefs were respected. Staff enjoyed working in the home and listened to what people had to say so they understood what was important to them. There wer

The inspection took place on 1and 3 February 2017. The visit was unannounced on 1 February 2017 and we informed the operations manager and home manager we would return on 3 February 2017.

Willow Tree Nursing Home provides accommodation, nursing and personal care and support for up to 47 older people. The home has two units. Cedar unit provides accommodation for older people living with complex health care conditions and physical frailty. Oak unit provides accommodation for older people living with dementia and / or physical frailty. At the time of our inspection visit 36 people lived at the home.

The home is required to have a registered manager in post. 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 and associated Regulations about how the service is run. Following our last inspection in October 2016, the operations director informed us that the registered manager had agreed to a change in their role at the home and was to undertake the deputy manager role. A new manager had started working at the home during November 2016 and told us they intended to submit their application to become registered with us.

When we inspected the home in March 2016 we found the legal requirements and regulations associated with the Health and Social Care Act 2008 were not being met. Breaches of the regulations related to the safe care and treatment of people, gaining people’s consent and the governance of the home. A requirement notice was served on the provider to tell us what action they would take to make improvements. At our last inspection in October 2016, we found improvements had not been made. We identified continued breaches of the regulations. A continued breach in the unsafe management of medicines and the governance of the home resulted in enforcement action being taken and we served warning notices on the provider and the registered manager. The home was placed in ‘special measures.’ The special measures framework is designed to ensure a timely and coordinated response where we judge the standard of care to be inadequate. Services in special measures are inspected again within six months following the publication of the inspection report.

At this inspection we looked to see if the provider had responded to make the required improvements in the standard of care to meet the regulations. We found that sufficient improvements had been made to remove the service from ‘special measures.’

We checked to see if the requirements of the warning notices served had been met and found they had. Improvements had been made and further improvements were planned for.

Systems were in place to assess the quality of the service provided. Improvements had been made to numerous systems, such as the tools used to audit. However, some audits were not always effective and further improvements were required.

Feedback was sought from people and their relatives, improvements had been made in response to feedback received in the areas that mattered most to people. Staff felt supported by managers and that a positive culture was being nurtured and developed in the home. Staff felt they could approach the manager to raise concerns if needed.

Improvements had been made in the safe management of medicines. People had their prescribed medicines made available to them by trained staff. Further improvements were required in the guidance made available to staff about medicines with specific instructions such as eye drops and ‘when required’ medicines. Improvement was also required in records for people that received their medicines in a ‘covert’ way.

Risk assessments to minimise where people may be at risk of harm or injury and the required actions, had been taken. However, people’s wound care records did not always conta

The inspection took place on 3 and 4 October 2016 and it was unannounced.

Willow Tree Nursing Home is provided by Culpepper Care Limited. Willow Tree Nursing Home provides accommodation, personal care and support and nursing care for up to 47 older people. The home has two units. Cedar unit provides accommodation for older people living with complex health care conditions and physical frailty. Oak unit provides accommodation for older people living with dementia and physical frailty. At the time of the inspection 44 people lived at the home.

Willow Tree Nursing Home was last inspected by us in March 2016 and we found breaches of the regulations. These related to the safe care and treatment of people and the need to gain people’s consent and the governance of the home. We gave the service an overall rating of ‘requires improvement’ and asked the provider to send us a report to tell us how improvements were going to be made to the service provided. At this inspection we found the provider had not implemented their planned improvements to meet the requirements of the regulations.

The home is required to have a registered manager in post. 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 and associated Regulations about how the service is run. At the time of this inspection the home had a registered manager in post.

Systems in place to assess the quality of the service provided were not always effective and improvement had not been fully implemented as planned. Risks associated with the management of medicines and people’s care and treatment had not been identified by checks undertaken. Feedback was sought from people and their relatives but negative comments were not always investigated or acted upon. The registered manager did not always investigate concerns about poor care practices raised with them.

There was not a system to ensure that the management of medicines was done safely. People had not always received their medicines as prescribed because they had run out. Discrepancies in stock and records meant we were not able to check that some medicine had been given as prescribed as the amount of medicines available did not match the records of receipt or administration.

Assessments to identify where people may be at risk of harm or injury did not always ensure that the risk was minimised. Some risks had not been assessed and staff did not have the information available to refer to, if needed, to know how to minimise risks.

Most people felt safe living at the home because staff were there to support them when needed. A few people did not feel consistently safe at night because they had experienced people entering their bedrooms. Staff were trained to know what abuse was and how to report any concerns to the registered manager.

Staff worked within the principles of the Mental Capacity Act (MCA) 2005 when supporting people with personal care. The provider used closed circuit television surveillance in communal areas of the home but could not show us how they had consulted with people and their families about its use. The registered manager had not always acted in accordance with the MCA. People’s liberty was only restricted when the proper authorisation had been sought.

People had choices offered to them about what they wanted to eat and drink and were supported to maintain their health and see a GP, for example, if they felt unwell.

Staff had received training and felt this gave them the skills and knowledge they needed to meet people’s needs effectively. Staff promoted people’s privacy when they were supported with personal care.

People felt most staff were kind and had a caring approach to them, however, this was not consistent with all staff. Some people felt a few staff were no

The inspection took place on 1 and 2 March 2016. The visit was unannounced on 1 March 2016 and we informed the provider we would return on 2 March 2016.

Willow Tree Nursing Home provides accommodation, personal care and support and nursing care to up to 47 older people. The home is divided into two units; Cedar unit provides accommodation for people living with health care conditions who are physically frail due to older age, and Oak unit for people living with dementia. At the time of the inspection 39 people lived at the home.

The home is required to have a registered manager in post. 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 and associated Regulations about how the service is run. There was a registered manager in post.

The Local Government Ombudsman (LGO) had informed us, in November 2015 that the provider was required to submit an action plan outlining their plans to make improvement to care records at the home. The LGO investigates complaints, for example, about adult social care providers. As part of our scheduled inspection to see whether the provider was meeting the regulations, we looked at people’s care records. Some records we requested to look at could not be located and some care records did not contain the information staff needed for information about people’s care needs. One person’s food chart was not an accurate record of what they had eaten.

People had their prescribed medicines available to them; however, prescribed items were not always safely managed by staff. For example, creams and eye drops were not dated on opening. The manager could not be sure people always had creams applied as prescribed because records were incomplete and no effective system was in place to check.

Risks associated with people’s care had been assessed and actions were described to reduce the risk of injury and harm, but these were not always followed by staff.

The storage arrangements of some medical items presented a risk of contamination or infection. Areas of the home were visibly dirty. Some areas of the home were in need of maintenance. For example, we found torn lino in a kitchenette that prevented effective cleaning.

Staff had completed some training to deliver care and support but there were no checks or assurance they had training that had equipped them, with the skills or knowledge they needed to undertake their roles. Staff had a limited knowledge of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards and staff were not aware of their responsibilities under this Act.

Most staff had a caring approach to people and were kind and compassionate. People were not always treated with dignity. People and their relatives were involved in making choices or decisions about their care.

Most staff knew people’s needs, however, people’s care plans did not always contain the information for staff to refer to if needed. Staff did not always respond to people’s needs. Social activities took place as planned for and people were offered choices about their food.

Some systems were in place to assess the quality of the service provided but these were not effective. We found there was insufficient oversight, from the provider, to check delegated duties had been carried out effectively.

We found 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.

We visited the home on 2 April 2014. We spoke with the manager, the operations director and five staff. People who lived at the home were not able to tell us how they were cared for because of their complex needs. However, we spoke with three relatives, looked at people’s care plans and observed how people were cared for.

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

Is the service safe?

The care plans we looked at showed that the nursing staff and manager assessed risks to people’s health and well-being and their care plans included measures to minimise their identified risks. The manager arranged the staff rotas according to people’s needs and additional staff worked during the periods when people most needed support.

The home had a policy and procedures related to the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards, although no applications needed to be submitted to the local authority. A registered mental health nurse assessed people’s mental capacity to make decisions relating to their care and treatment. For those people who did not have capacity, their relatives and other health professionals were involved in making decisions in their best interests.

We found that systems were in place to ensure that managers and staff learnt from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. Staff told us that the manager took action to minimise the risks of a re-occurrence.

Is the service effective?

People’s health and care needs were assessed with them and their relatives, and they were involved in writing their care plans. Specialist dietary, mobility and equipment needs were identified in people’s care plans where required. We saw that people’s care plans were reviewed every month and updated to reflect their changing needs.

Relatives we spoke with told us they could visit whenever they wanted to. They told us that staff were proactive and understood their relations’ needs and preferences.

Staff attended mandatory training, such as, moving and handling, food hygiene and infection control. Nurses attended specialist training that was relevant to the needs of people living at the home. Staff told us the manager was very supportive. They told us they had regular team meetings and one to one meetings so they could discuss best practice and their personal development needs.

Is the service caring?

People were supported by kind and attentive staff. People were supported to complete a life history book, including a family tree, ‘important people’, my childhood, teenage years, working life and interests, so that staff could get to know them better.

We saw that care workers were patient and encouraging with people. Staff knew people well and understood their individual needs for practical support and companionship. Staff encouraged people to reminisce and talk about their own interests if they did not want to join in the group activities. A member of care staff told us, “The afternoons are quieter, so we can chat with people, they tell us about their past, they are proud of their life and like telling us.”

Relatives told us that staff respected their relations and treated them as individuals.

People commented, “The staff are friendly, I know them well. I go to relatives’ meetings. They do listen.” People using the service and their relatives were encouraged to make suggestions and comments about the service at regular open meetings with the manager and activities coordinator.

Is the service responsive?

Staff asked other health professionals to visit people when they had concerns about their health. Staff recorded the health professionals’ advice and the actions they took following their advice. This meant that people’s response to treatment was monitored and could be changed appropriately. Staff we spoke with were knowledgeable about recent changes to people’s treatments and described which treatments had been effective and which were ongoing.

Staff recorded when people saw their dentists, chiropodists and opticians, for example, so they could ensure that regular health checks were maintained. Relatives told us that they could read the daily records of care which assured them their relations received the care and support they needed. Relatives told us that the staff and manager responded appropriately when they had any concerns or issues. A relative told us, “The manager addresses issues quickly, I’m impressed.”

Is the service well-led?

We found the service had an effective quality assurance system in place and identified actions had led to improvements in the service that people received. The manager carried out a regular programme of audits and checks to make sure the quality of the service was maintained.

The manager was supported by a care lead and clinical lead member of staff. All nurses were designated leads for different aspects of care or treatment, such as, tissue viability, mental health and infection control. Each lead nurse was supported by a team leader and care assistants. Staff we spoke with knew and understood their individual and shared responsibilities. Staff told us that recent changes in management, staffing and shift patterns had enabled and supported them to deliver good quality care.

Most of the people who lived at the home were not able to tell us what it was like to live there, so we spent time observing care and support. We spoke with three relatives, who told us that their relations were happy at the home. We saw that people were relaxed with staff and appreciated their company. Staff spoke reassuringly with people when assisting them.

In the eight care plans we looked at, we saw that people's needs and abilities were assessed before they moved into the home. Care plans identified risks to people's health and wellbeing, with appropriate guidance for staff. Staff knew and understood the changes in people’s needs, but changes were not clearly recorded in their care plans. People's care plans were not regularly reviewed.

We found the home was clean, tidy and free from infection. Staff used appropriate equipment to minimise the risks of infection.

We saw there were not enough staff to meet people’s needs in a timely and effective way. The five staff we spoke with told us they did not have enough time to make sure that everyone was cared for at their preferred times.

Staff were not sufficiently supported by the manager. Staff did not have regular one-to-one meetings with senior staff, to reflect on their practice and consider their personal development.

The provider’s quality assurance system was not carried out effectively. Action plans resulting from the manager’s checks were not completed within the agreed timeframe.

We used a number of different methods to help us understand the experiences of people using the service. This was because some of the people who used the service had complex needs which meant they were not all able to tell us their experiences.

During the inspection we spoke with twelve people who used the service and four visiting family members. We also spoke with the manager, two nurses and five care assistants.

People who used the service told us they were happy living at the home and that they were well looked after. One person said, “I have only been here a short time but I would definitely recommend it to anyone.” A visiting family member told us, “I think the staff look after my relative well. Since they have been here, they are eating better and their heath has improved.”

We looked at records which stated how people liked and needed to be cared for. People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. The care staff we spoke with demonstrated an understanding of people's needs.

People told us they felt safe and able to report any concerns they may have. One person told us, “I have nothing to complain about.”

In this report the name of a registered manager, Isabelle Finister, appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time.

We visited the Willow Tree Nursing Home on 11 June 2012. The visit was unannounced so that no one living or working in the home knew we were coming.

Following our last review of the service on 12 March 2012 we had concerns about the care and welfare of people using the service. We told the provider they must make improvements to the management of medicines, which were set out in a warning notice. This notice contained details of specific areas where improvements were required.

We found during this visit that appropriate improvements had been made in the storage, administration and handling of people's medicines to meet the requirements of the warning notice.

The home is made up of two units, each of which has a designated staff team. We spent time in each unit and spoke with four people who use the service, as well as five members of staff on duty during our visit.

We received positive comments about the staff team from a visiting health care professional we spoke with. We were told, “The home has improved over the past few months. People are much more settled and I feel the staff are now meeting people’s needs.”

We saw that people’s needs had been assessed before they moved in to the home. Care plans had been devised to describe how people liked and needed to be supported. Risks to people’s health and well being had been identified and measures had been put in place to protect people.

Staff were familiar with people’s needs and we observed that staff were friendly and supportive in their approach towards people. One person commented, “They’re all very nice here. I’m content.”

Following our last review of Willow Tree Nursing Home on 10 November 2011 we had concerns about the care and welfare of people using the service. We told the provider they must make improvements. We received an action plan from the provider telling us what they were going to do to ensure the necessary improvements were made.

We carried out this visit to check that improvements had been made and to confirm the service was now compliant. We found that whilst there had been some improvements made, further actions were needed to achieve full compliance. We are taking further action in respect of this.

During our visit we spoke with three people living in the home and two visiting relatives. We also spoke with three staff members, the manager and the compliance manager for the organisation.

People told us they received the care they needed. One person commented, “I am quite happy here.” A visiting relative commented, “Things have improved in the home in the past few months, I have no complaints about the care my relative is receiving."

Staff were familiar with people’s needs and we observed that staff were friendly and supportive in their approach towards people.

We looked at how the home ensured people received their prescribed medication in a safe manner. Records we reviewed did not demonstrate that medicines were given safely and as prescribed.

We carried out this responsive review because we had received information that the

standard of care provided at Willow Tree Nursing Home had put people at risk of not having their care needs met.

We made an unannounced visit to this care home on Thursday 10 November 2011.

There were 34 people using the service when we visited.

During our visit we spoke with the operations manager, two nursing staff and three care staff. We spoke with eight people who live at Willow Tree Nursing Home. Some people who use the service were not able to express their views to us, so we observed interaction between people and staff to see how they experienced care.

The people we spoke with told us they were generally satisfied with the care and support they receive. One person told us, “Staff always seem to be so busy, I don’t like to make a fuss.”

We saw a mixed approach by staff in the way they involved people and respected their dignity. Some staff showed empathy towards the people they cared for, while others concentrated solely on meeting people's individual personal care needs.

We looked at how the home ensured people received their prescribed mediation in a safe manner. Records we reviewed did not demonstrate that medicines were given safely and as prescribed.

We found that the service was failing to meet the essential standards we checked.