The Willows

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

People’s rights were not always protected in line with the Mental Capacity Act. We were not assured that capacity assessments and best interest decisions were in place for all the people, who lacked capacity to make decisions. This was a breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

We received concerns about the food provision in the service, with several people telling us the food was not always hot. A person told us they had chosen to eat their meals on the ground floor as they felt the food was hotter there. Another person said, “The food is not always good. I had cottage pie and it had great big lumps of mince. The potatoes and carrots are always hard. The rice is so thick I tell them to take it and put milk in it. The crumble was all doughy and the rhubarb sour. We had stew and dumplings the other day and the dumplings were like a bread roll.” Another person showed us photographs of some meals, which they had taken as evidence as they did not feel listened to [by the provider] when raising concerns about the food. During our assessment we spent time observing lunch. One person had finished eating their meal and their relative pointed to the remains on the plate and asked us, “Would you eat it?” The food did not look appetising and the broccoli on the plate looked dry. Another relative told us, “One day a sandwich was served to my [family member] which had fruit salad in juice on the same plate. Everything was wet.” A relative told us they often asked what their family member had eaten and were given a percentage amount to describe this, however, they felt there were inconsistencies and inaccuracies in the information they were provided with. We also found the records were inconsistent, for example a person’s care notes stated they only at 20% of their meal and yet they also stated the same person ate all of their food. This was of particular concern where people were at risk of malnutrition and their intake needed closely monitoring for their good health. Mealtimes were not well coordinated, and staff were not skilled in supporting people in a dignified and respectful way or in the way which was identified in their care plan and communication with people was limited.

Catering staff showed us a white board in the kitchen which identified people’s specific dietary needs. They told us how they were working to ensure people who required a diabetic diet, for example, had appropriate foods. A member of the catering staff said people could have cooked breakfasts if they wanted one, however, during our visits we saw people had cereal and toast. We asked a person if they had their breakfast and they said not yet and they liked bacon and egg. They did not get this for their breakfast.

People’s care records did not always include their preferences of food and drink. A person’s relative told us what their family member did not like to eat, and sometimes the 2 meal choices were what their family member did not like, and the staff had not offered an alternative when they were getting people’s choices, this was not documented. A person told us they did not like a certain item and had made staff aware, but the food continued to contain it. A person’s daily notes stated they had been given a drink which was slightly thickened, however their care plans stated they had thin drinks. This placed them at considerable harm of having a drink at the wrong texture which would place them at risk of choking. The amount of drinks people were offered each day and actually drank was being recorded. However, where people had not met their suggested targets, we did not see any information in their care notes where this had been reported, the care plans did not state when to contact health professionals if there were concerns of dehydration. For example, 1 person had the target of 1500mls a day, the average from 7 to 21 March 2024 was 687mls. One day their fluid intake was recorded as being offered 150mls and drinking 75mls. This increased the risk of people becoming dehydrated.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

A person told us, “I saw the nurse today who took my bloods, I see the GP when I want to.” Despite this, we could not evidence this level of healthcare support because care records were not always updated and reviewed. A relative told us they had asked staff about their family member’s nail care and had been told the chiropodist had been, but it was not always clear if they had seen their family member and felt they had not as they had not been billed for the service. They based this judgement on their observations of the lack of care to their family member’s nails.

The registered manager and management team had not identified the significant shortfalls we had during our visits. In addition, they had also not identified the shortfalls noted by the local authority. The chief operating officer told us actions would be taken to improve, and the overarching improvement plan would be updated to reflect the improvements needed.

Records showed people had been supported to see health professionals where required and an outcome of the visit and guidance received was recorded. However, this was not always incorporated into their care plan and being followed by staff which placed people at risk of harm. For example, the speech and language therapist team (SALT) had provided guidance for a person to be supported to sit up during their meals due to the risk of choking, however, we saw this person eating whilst leaning over the side of their chair.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. People’s views varied about if they felt listened to and if their consent to care was sought. During our visits, we saw whilst some staff asked for people’s consent before providing any support, some staff did not and were task focussed. We also had wider concerns about how people were supported and how their rights under the MCA were respected.

The registered manager confirmed the numbers of people who had a DoLS in place, however, despite this we were concerned about the non-compliance with the Mental Capacity Act. People’s capacity had not been considered and recorded in all areas of their care.

We were not assured that capacity assessments and best interest decisions were in place for all the people, who lacked capacity to make a decision to have a gate at their bedroom door. We asked the registered manager to check how many people had gates and how many lacked capacity and if the documents were in place on our first visit, this information was not provided. From the care records we reviewed, we did see people’s capacity was assessed in some other areas, and where required DoLS had been applied for. The care records did not always identify guidance for staff on any DoLS restrictions that been applied as part of the authorisation. In addition, the capacity assessments did not include all areas of the care provision when people lacked capacity to make their own decisions.