This unannounced inspection took place on 27 February 2018.

Willowbrooke Residential Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. The care home accommodates 19 people. At the time of the visit there were 16 people who received support with personal care. There is no nursing care at this service.

At the time of our inspection there was no registered manager in post. The registered manager had recently left. A new manager had been appointed and was in the process of completing an application to become the registered manager. 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.

At the last inspection in March 2017, we found shortfalls in a number of areas. This included shortfalls in the effective management of risks to receiving care and a failure to implement systems and processes for seeking consent and mental capacity assessments. We also found shortfalls in the governance systems. This included a lack of evidence to demonstrate the oversight provided to the registered manager to ensure compliance. The provider had also failed to implement systems and processes for auditing and assessing the quality of the care. These were breaches of Regulation 11, 12 and17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Following the last inspection, we took enforcement action and issued the provider with a warning notice for the failure to maintain good governance and for failing to seek consent. We also met with the provider and asked them to complete an action plan to show what they would do and by when to improve the key question(s), ‘Is the service safe, Is the service effective, and Is the service well-led?’ to at least good.

During this inspection we reviewed actions the provider told us they had taken to gain compliance against the warning notice and breaches in regulations identified in March 2017. We found necessary improvements had been made in relation to the management of risks to receiving care, the safe management of medicines and seeking consent. We also found significant improvements had been made in relation to good governance and the provision of oversight at the service.

We received positive feedback from people and their relatives regarding the quality of the care delivered. Visiting professionals we spoke with also gave positive feedback about the service. People who lived at the home told us that they felt safe and spoke highly of the owner and the care staff.

We found there had been significant improvements to the quality of care provided since our last inspection. The registered provider and their staff had made necessary improvements to address the shortfalls we found in March 2017 to ensure the service was compliant with regulations. Necessary improvements had been made to the management of risks to receiving care. Risk assessments had been developed and reviewed to minimise the potential risk of harm to people who lived at the home.

People told us they received their medicines as prescribed and staff had been trained in the safe management of medicines. Improvements had been made to the management of topical creams and thickening powders. Regular medicine audits had been carried out and issues were identified and rectified promptly.

There were significant improvements to processes for seeking consent. The staff who worked in this service made sure that people had choice and control over their lives and supported them in the least restrictive way possible. Staff had improved th

We carried out an unannounced inspection at Willowbrooke Residential Home on 15 and 17 March 2017.

Willowbrooke Residential Home is a residential care home providing personal care for older adults. They provide care for a maximum of 19 people. The accommodation is over two floors with a passenger lift to both floors. Communal areas comprise of one lounge area, a conservatory and a dining room. There is an enclosed garden and a car park. The home is located in Lostock Hall, near Preston and is situated close to local shops and amenities. There were 19 people who lived there at the time of our inspection.

The service was managed by a registered manager. A registered manager is a person who has registered with the Care Quality Commission (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.

At our last comprehensive inspection on 4 December 2015, we found the provider was not meeting three regulations. We therefore asked the provider to make improvements to safeguarding people from abuse and improper treatment, safe care and treatment and seeking people’s consent. Following the inspection, we asked the provider to complete an action plan indicating how and when they would meet the relevant legal requirements. They did not send us the completed action plan.

During this inspection we reviewed what actions the provider had taken to improve the service. We saw that significant work had taken place since our last inspection to improve the safety, effectiveness and quality of the service. However, some further improvements were required in respect of medicines management and planning for people’s care. Improvements made in relation to seeking people’s consent and systems, governance and processes for assessing the quality of the service were not enough to ensure compliance with regulations.

We found the service continued to be in breach of two regulations under the Health and Social Care Act, 2008 (Regulated Activities) Regulations 2014. The breaches were in respect of Regulation 12, safe care and treatment and Regulation 11, seeking consent. We also found a breach of Regulation 17, good governance. This included shortfalls in the effective managements of environmental risks within the service and a failure to implement systems and processes for auditing and assessing the quality of the care. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Before this inspection, we had received some concerning information in relation to poor personal care, dignity and respect, and lack of knowledge and skill to care for people living with dementia. We looked into these areas during the inspection.

Feedback from people and their relatives regarding the care quality was overwhelmingly positive. Views from all the visiting professionals we spoke with were positive.

People who lived at Willowbrooke Residential Home told us that they felt safe and there was sufficient staff available to help them when they needed this. Visitors and people who lived at the home spoke highly of the registered manager, staff and the nominated individual. They told us that they were happy with the care and treatment.

Since the last inspection in December 2015, a new care plan system had been introduced and this had led to an improvement in the way people’s care records and risks assessments were written.

There were up to date policies and procedures in use by staff however they had not always been followed.

We saw copies of satisfaction surveys that had been completed by people who lived at the home. The majority of these surveys demonstrated people thought their care and the staff who supported them were excellent.

We looked at how the service

This was the first inspection of Willowbrooke Residential Home. The service was registered in April 2015.

Willowbrooke Residential Home is a newly refurbished care home for older adults. They provide care for a maximum of 19 people. The home is located in Lostock Hall Preston and is situated close to local shops and amenities.

The registered manager was on duty on our arrival and received feedback throughout the inspection. 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 who lived at the service told us that they felt safe.

We looked at how the service protected people against bullying, harassment, avoidable harm and abuse. We found that staff had received training in safeguarding adults and demonstrated a good understanding about what abuse means.

However we found that the service had not always made safeguarding referrals in line with their policy and procedure. For example one person had made allegations about the care they received. We discussed this with the registered manager who took immediate action to follow necessary safeguarding procedures.

We found that the registered manager, deputy manager and care workers lacked knowledge and understanding about referral processes around Deprivation of Liberty Safeguards (DoLS). We looked in a person's care records and found reported instances when they had requested to leave the service. A DoLS application was not made despite the person repeatedly asking to leave. We discussed this with the registered manager who took immediate action.

We looked at how the service identified and managed risk for people on an individual basis. We found that the service completed risk assessments for many areas of care and support for example; nutrition, falls and moving and handling. However, identified risk was not always included in care plans to ensure that management of known risk was undertaken. We have made a recommendation regarding this.

Risk assessments were in place for the premises and audited on a regular basis. However we found omissions in fire risk assessment and checking water temperatures. This meant that the service had not effectively assessed and prevented avoidable harm.

The service had robust recruitment policies and procedures in place, which we saw in operation during the inspection. We reviewed five staff files and found that pre-employment checks had been carried out.

We found that the service had sufficient numbers of staff on duty to keep people safe and meet their needs. Staff told us that staffing was sufficient. There was no formal staff dependency tool however the manager and provider assured us that staffing levels were continually assessed in line with the needs of people who lived at the service.

We looked at how the service managed people's medicines. We found significant shortfalls in stock management, recording of medicines administration, controlled medicines and care planning around people's individual medicine needs and preferences. These shortfalls meant that people were at risk of not receiving their medicines as prescribed, we found instances when people had not received their medicines due to the service not having sufficient stock in place.

The service was exceptionally clean and infection control systems were in place and understood by staff.

We saw that the service had a detailed induction programme in place for all new staff. The induction covered important health and safety areas, such as moving and handling, working in a person centred way and first aid awareness.

Staff told us that they felt supported in their roles and had received training to help them understand their role and responsibilities.The service did not have a training matrix in place, however we looked at staff files and found evidence of training certification.

Staff told us that they received supervision as part of their probationary period. No further supervisions had been completed. We looked at a supervision contract that was signed by staff, it stated that supervisions would be completed ‘as and when required’. There was no formal policy in place for the frequency of staff supervisions. We made a recommendation about scheduling supervisions to ensure that staff had continued support.

It was evident from review of training records and discussions with staff that there was a lack of training around dementia care. The manager agreed that this was a training need at the service.

We asked staff if they had received training in the Mental Capacity Act 2005 (MCA 2005). Staff told us that they had completed e learning. However, we found that they had limited knowledge. In addition, staff were unable to explain the basic principles of the act and when to apply it. We asked about Depravation of Liberty Safeguards (DoLS) training. Staff were not clear about when they would need to use these safeguards and how they would do this.

We found that the service did not assess a person's mental capacity in line with the MCA 2005. People who lived at the service and their representatives were asked to sign consent and agreement documents. The service had not effectively recorded consideration of the person's mental capacity.

We found that the service had effective systems in place for assessing people's risk of malnutrition. We observed people enjoy meal times during the inspection and people gave positive feedback about the quality and quantity of food they were provided.

We looked at how the service supported people to maintain good health. We received positive feedback from external health care professionals. We looked at people's care records and found that the service had referred people for support from external health care professionals on most occasions. However we found two instances when people had not been referred to external professionals.

The environment was adapted for people living with physical disability. An excellent standard of decoration had been developed throughout the service and people were happy with the standard of individualisation in their bedrooms.

We received very positive feedback about the care provided from people who lived at the service, their representatives and visitors.

We observed staff approach people in a kind and dignified way. We saw that staff had built trusting relationships with people who lived a the service.

We spoke with the provider. The provider told us that it was important for the service to provide kind care that was based on people's individual needs and preferences.

We received positive feedback from a visiting palliative care nurse about the good standard of end of life care and support provided by the service.

We found that the service provided a good standard of person centred care. We looked at people's care plans and found that they reflected people's needs and preferences.

We observed people receive care that was tailored to their needs and preferences and people told us that they were encouraged to lead an enriched life.

We looked at how the service listened to people's experiences. We found that satisfaction surveys were issued. Action planning around people's feedback was not formally recorded. However, the registered manager explained actions had been taken and we were able to see this during our inspection. For example, one person had requested footstools in the lounge and these had been put in place for residents to use.

People told us that they felt listened to and had been given the opportunity to have their say.

We found that the service displayed the complaints procedure this enabled access to information about how to complain for people who lived at the service and visitors.

We looked at people's care records and found a good standard of information for when people had been transferred between services. People had been escorted by staff when they preferred to hospital and community appointments.

We looked at how the service demonstrated good management and leadership. Staff told us that they felt supported by the provider, registered manager and deputy manager.

People who lived at the service felt involved with the general running of the home and told us that the provider and registered manager were always available if they wanted to speak to them.

We observed a positive staff culture and staff told us that they enjoyed working at the service.

We found that the service had systems in place to monitor the delivery of care, however the registered manager had not yet implemented these systems and quality assurance had not been adequately considered.

We looked at staff meeting minutes from September 2015 and found that shortfalls in medicines management had been identified. We found that these shortfalls were still happening and had not been adequately addressed.

We also found that the registered manager had failed to ensure that some necessary safety checks had been undertaken despite completing a monthly risk assessment that covered risk management for fire and water temperature safety. We made a recommendation about improving quality assurance systems at the service.

We found the registered manager receptive to feedback and keen to make immediate improvements. The registered manager emailed us after the inspection to confirm what immediate actions had been undertaken to address the shortfalls found.

We found the provider was in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This related to safeguarding, safe care and treatment, premises safety and need for consent. You can see what action we have told the provider to take at the back of the full version of the report.