What life was like for people using the service:

Since the previous inspection the management team and staff had worked hard to make necessary improvements to the service and the quality of care provided. The Willows had undergone some refurbishments to make the home safer and more visibly appealing. The work completed had also made the environment more meaningful for people living with dementia. The registered manager and deputy manager told us of their plans to further develop the environment to promote more positive engagement, stimulation and socialisation for people living in the home.

The atmosphere at The Willows was now calm and homely; the management team and staff had developed strong, familiar and positive relationships with people and family members. Throughout the inspection the registered manager, management team and staff were seen to be warm and affectionate towards people and often displayed physical contact that was appropriate and accepted by people.

Staff showed a genuine motivation to deliver care in a person centred way based on people’s preferences. People were treated with kindness, compassion and respect. Staff used techniques to help relax people with positive outcomes. Everyone we spoke with told us The Willows was now a more homely place to live.

People told us they felt safe living at the service and family members were confident their relatives were kept safe. Risks that people faced were identified and assessed and measures put in place to manage them and minimise the risk of harm occurring. Staff showed a good understanding of their roles and responsibilities for keeping people safe from harm. Medicines were managed safely and people received medication at the right time. The environment was safe and people had access to appropriate equipment where needed.

Enough suitably qualified and skilled staff were deployed to meet people’s individual needs. The registered manager had recently recruited new permanent staff and told they would continue to do so. On some occasions agency staff were used to cover any shortages with staffing numbers. Staff received a range training and support appropriate to their role and people's needs.

People’s needs and choices were assessed and planned for. Care plans identified intended outcomes for people and how they were to be met in a way they preferred. People told us they received all the right care and support from staff who were well trained and competent. People received the right care and support to eat and drink well and their healthcare needs were understood and met. People who were able consented to their care and support. Where people lacked capacity to make their own decisions they were made in their best interest in line with the Mental Capacity Act.

People received personalised care and support which was in line with their care plan. People, family members and others knew how to make a complaint and they were confident about complaining should they need to. They were confident that their complaint would be listened to and acted upon quickly.

The leadership of the service promoted a positive culture that was person centred and inclusive. People, family members and staff all described the registered manager and deputy manager as supportive and approachable. The management team showed a continued desire to improve on the service and worked closely with other agencies and healthcare professionals in order to do this. Effective systems were in place to check on the quality and safety of the service and improvements were made when required.

More information is in Detailed Findings below

Rating at last inspection: Inadequate (report published 15 May 2018).

About the service: Willows Care Home is situated in Blacon, Chester. The service accommodates up to 73 people over three separate units and provides nursing and personal care. Some people using the service are living with dementia. At the time of the inspection 40 people were living at the ho

We previously inspected Willows Care Home in October 2016 and the service was rated Requires Improvement overall. We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in respect of Regulations 10 and 18. This meant the registered provider had failed to ensure people were treated with dignity and respect and also staff had insufficient induction and training. After the comprehensive inspection, the registered provider wrote to us to say what they would do to improve and meet legal requirements.

At this inspection we identified new and repeated breaches of the regulations. These were in relation to assessing and mitigating risks to people’s health and wellbeing, safe care and treatment, meeting nutritional needs, dignity and good governance.

We will update the section at the end of this report to reflect any enforcement action taken once it has concluded.

Willows Care Home is a ‘care home’. People in care homes receive accommodation and nursing or 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 care home accommodates 73 people. There are three separate units, each of which has some separate facilities such as bathrooms and sitting areas. At the time of the inspection 54 people were living at the home.

There was a registered manager. 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.

Quality assurance systems were in place but these had again failed to identify risks presented to the people who lived at the home. The registered provider did not address the concerns raised during this or the previous inspection. The registered provider had failed to notify the CQC of some notifiable incidents. There was insufficient analysis of accidents and incidents (such as falls) in order to learn from them and mitigate risk.

People could not be assured that risks to their safety were always fully assessed or kept under review. Risks were not always reduced as much as possible and therefore, the registered provider was not taking reasonable steps to keep people safe.

People lived in an environment which required repair and refurbishment in order to fully meet their needs. Premises were not visibly clean or free from odour. This meant that there was an increased risk of acquired infection.

People had medication as required and these were recorded and administered correctly. However, some medications such as creams and thickening agents were not stored in accordance with good practice guidance which placed people at risk of harm.

People had a mixed opinion of the meals that they received although families felt it to be sufficient. The food prepared was not always kept hot or served quickly which impaired a person’s enjoyment of their meal. Others were served puree meals when they had been assessed as able to eat a variety of soft foods. Staff did not provide adequate assistance where people required support to eat or drink sufficient amounts.

People were supported by staff that they described as were caring; however from observation we saw that people could not always be assured that they were treated with dignity and respect. We found that staff did not respond quickly to meet people’s needs and lack of adequate monitoring placed people at risk of harm.

Care plans were detailed and person centred. However, these were not always updated following any changes. The care and support of people who lived at the home did not always follow their care plan requirements. This meant that there was a risk that their needs were not fully met.

Improvements had been made to the staff induc

The inspection took place on the 26 and 27 September 2016 and the first day was unannounced.

Willows Care Home is split into three units that support people with conditions associated with old age and physical disability as well as people living with dementia. The service is registered to accommodate a maximum of 73 people. At the time of the inspection there were 51 people living at the service.

The last inspection of the service took place on the 20 and 21st August 2015 and at the time the service was meeting the regulations we assessed.

There was a registered manager who was registered in September 2016. 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.

We found that the registered provider was not meeting all of the requirements of the Health and Social Care Act 2014 and you can see what action we told the provider to take at the back of the full version of the report.

Staff supported people in a patient manner and it was evident that relationships between people and the staff that supported them had been developed. People who used the service told us that they felt safe and well cared for. Relatives were happy with the care that people received and they expressed no significant concerns. However, we observed that people were not always treated with dignity and respect. This was particularly where people were supported in bed or required assistance during meal times.

At the last inspection we made a recommendation that the registered provider improved people’s dining experience. We found that this was still variable and improvements required around support for people living with dementia. People told us that they liked the food and there was a choice of meals available. Although people received the help they required with eating and drinking, their independence was not always promoted.

Staff did not all receive an induction that met with the requirements of the care certificate framework to ensure that they had the skills and knowledge to carry out their job. Staff competency to carry out their role was not assessed before or during their period of employment. This meant that the registered provider could not be assured that they had the right skills, knowledge and values. Staff were provided with regular training but there was no system in place to assess how staff demonstrated the skills they had learn in their day to day work. Staff told us that they felt supported. However, one to one support and supervision was not provided in line with the registered providers own policy.

The environment and the building required improvement to ensure that it was clean, well maintained and met the needs of the people that lived there. The registered provider had commenced a programme of refurbishment and improvement that was planned to be completed by December 2016.

People were cared for by staff that had undergone the appropriate recruitment and selection checks to ensure that they were of suitable character for the job. Further checks were required to verify references provided.

The registered provider had a quality audit system in place to monitor the safety and effectiveness of the service. This identified both areas of concern and areas for improvement. We saw that actions were taken where concerns had been highlighted to minimise the risk of reoccurrence. The audits were not completely robust as they did not highlight all of the issues found on inspection.

The service had systems in place to ensure the safe administration and management of medication. Staff ensured that there was monitoring in place where people had specific health conditions. This meant that people received the correct treatment and support.

Activities took place a

Our observations showed that staff were very respectful towards people who used the service. We spoke with three relatives of people who used the service. They told us they had no concerns with the care and treatment provided.

We found that a plan was in place to refurbish all of the bathrooms at the home by end of 2013. In addition to this some bedrooms currently had new built in furniture.

We spoke with seven members of staff. They all told us they thought they had enough staff to meet the needs of the people who used the service. Two of them told us that they were always very busy but the needs of the people who lived at the home were always met on a daily basis. Staff also told us they always had the opportunity to have a meal break. Staff told us that they felt well supported and they had the information they needed for their roles. Comments from staff included; "The new manager has brought some good ideas to the table" and "I'm supported 100%. There's plenty of training opportunities."

We found there was an effective system in place to deal with complaints. It was evident there was a detailed audit trail of how concerns were managed and dealt with to the complainants satisfaction were possible.

We found that current records were kept securely and could be located promptly when needed. This included staff personnel files and clinical records for people who used the service.

We spoke to three people who use the service and a relative visiting at the time of our visit. They told us:

"I am keeping well in my health but if I become ill-they always get a doctor to me"

"The staff are very good"

"We are looked after here"

"I feel safe living here"

"They are very friendly and helpful"

"They do keep me informed of any changes to my relation's health-they have sometime been delays in this but on the whole they tell me"

"They do look after my relative's health and I think they are safe living here"

We found that staff were responsive to the needs of people but there were instances with two staff where interactions were limited and little communication occured between the members of staff and the people they supported. The health and well being of people was maintained and regularly reviewed.

The service does not always have arrangements in place to ensure that people were protected from abuse and we found that staff did receive occasional training and supervision. There were measures in place to measure the quality of care provided yet this did not extend to the provider providing a commentary on the care provided.

We carried out this inspection on the 20 and 21 August and the first day was unannounced.

The Willows Care Home is split into two units that support people with conditions associated with old age and physical disability as well as people living with dementia. The service is registered to accommodate a maximum of 73 people. At the time of the inspection there were 44 people living at the service.

There was 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. Since the last inspection, the compliance manager had left and the registered provider had employed a quality manager to assist and support the registered manager.

At the last focused inspection on 30 March and 1 April 2015, we found that a number of improvements were needed in relation to: people’s rights in decision making, medication administration, planning care and support, safety and suitability of premises and equipment, and the monitoring systems in place around the quality and safety of the service.

We asked the registered provider to take action to make a number of improvements. After the inspection, we issued warning notices in relation to the breaches identified. We instructed the registered provider to meet all relevant legal requirements by 27 July 2015.

During this inspection we saw that improvements had been made within the service in relation to planning and recording people’s care needs, staff training and support, the environment, the monitoring of the service delivered to people and to the overall management of the service. In addition, we found that the registered provider had taken action to address the concerns raised within the warning notices.

People who used the service told us that they felt safe and well cared for. Relatives were happy with the care that people received and they expressed no concerns. Staff supported people in a kind and patient manner and it was evident that relationships between people and the staff that supported them had been developed.

The service had made improvements to the safe administration and management of medication and the monitoring of people’s health conditions.

The registered provider had a safeguarding policy in place that staff were aware of. Staff identified safeguarding concerns and how to report them. Safeguarding incidents and low level concerns had been reported to the local authority and to the Care Quality Commission (CQC) where appropriate. The registered manager had made improvements to the recording of accidents, incidents and risks to people’s health and safety. Remedial action had been taken place to minimise risks, for example falls.

Following the last inspection the registered provider was required to ensure that people, who were deprived of their liberty, were done so in accordance with the requirements of the Mental Capacity Act 2005. Where a person’s liberty was being restricted or they were under continuous supervision, we found that the registered manager had made the appropriate application to the supervisory body under Deprivation of Liberty Safeguards. Where a person lacked capacity to make a specific decision or choice, staff documented why decisions had been taken in somebody's best interest. This meant that the rights of people not always able to make or communicate their own decisions were protected.

People told us that they liked the food and there was a choice of menu. We saw that although people received the help they required with eating and drinking, their independence was not always promoted. We have made a recommendation that the registered provider improve people’s dining experience.

People’s care and support needs were reviewed on a regular basis. Care planning documents were updated when required and appropriate referrals were made to healthcare professionals when required.

Activities took place and we saw evidence of this during our visit. Improvements were needed as to what activities were available for people to participate in. Some people told us that they did not always like the activity on offer and that they would like to do things that were more active or gave them the opportunity to go out more.

People were cared for by staff that had undergone the appropriate recruitment and selection checks to ensure that they were of suitable character for the job. Staff also had received induction and this followed the care certificate framework to ensure that staff had the skills and knowledge to carry out their job. Staff told us that they felt supported and had regular training and one to one support and supervision.

The registered provider had made improvements to the quality audit systems. This was more robust and identified areas of concern and areas for improvement.