CQC report explained · a residential care home
What the CQC found at OSJCT Willowcroft
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe and staff understood how to manage risks such as falls and pressure ulcers. There had previously been delays in reporting some injuries and incidents, but recent records showed improvement.
- Effective?
- Good
- This area was not assessed during this focused inspection. Its rating was carried over from the previous comprehensive inspection.
- Caring?
- Good
- This area was not assessed during this focused inspection. Its rating was carried over from the previous comprehensive inspection.
- Responsive?
- Good
- This area was not assessed during this focused inspection. Its rating was carried over from the previous comprehensive inspection.
- Well-led?
- Good
- The management team had quality checks, reviewed incidents and used a service improvement plan. People, relatives, staff and health professionals said managers listened and dealt with concerns.
What inspectors found, May 2022
Rated Good; inspectors found people were safe and well supported, with improvements made to incident reporting.
This was an unannounced, focused inspection on 26 and 27 April 2022. The inspection followed concerns about how injuries and incidents were managed. Inspectors spoke with people, relatives, staff and health professionals, and checked care records, medicines records, staff records and management records.
The home was rated Good for Safe and Well-led. People said they felt safe, there were enough staff and medicines were given on time. Risk assessments were in place and staff understood how to manage people's risks. Infection control arrangements were also found to be good.
There had previously been occasions when staff did not report injuries or incidents quickly enough. The manager had taken action, and recent records showed reporting had improved. The overall rating remained Good because the ratings for Effective, Caring and Responsive were carried over from the previous comprehensive inspection in 2020.
Medicines were recorded
Medicines records were complete and showed what people had been given. Instructions for medicines taken when needed were clear.
“Medicines administration records had been fully completed. These gave details of the medicines people had been supported to take” from the report
Enough staff
People said staff were available when needed. Inspectors found recruitment checks were in place.
“There were enough staff to meet people's needs. People told us staff were available to provide support when they needed it.” from the report
Good management checks
The management team checked care records, medicines, staff records and staff practice. They used the results to plan improvements.
“The provider had effective quality assurance systems in place.” from the report
Good partnership working
The manager worked with health and social care professionals to respond to people's needs and concerns.
“The registered manager had developed good relationships with health and social care professionals and worked with them to meet people's needs.” from the report
Earlier delays reporting injuries
needs fixingThere had been occasions when staff did not report injuries promptly, including after suspected falls. The manager took action and recent records showed this had improved.
“There had been some occasions when staff had not promptly reported incidents when people had been injured, for example following suspected falls.” from the report
Staff sickness
minorStaff said sickness absence had sometimes made it harder to meet people's needs. They said management support meant this had not affected the care people received.
“They said they had struggled at times due to sickness absence but received support from the management team to provide care.” from the report
- 01How do you make sure injuries, falls and other incidents are reported promptly every time?
- 02What changes were made after the earlier delays in incident reporting, and how do you check that they are still working?
- 03How do you maintain safe staffing levels when there is sickness absence?
- 04What actions are currently open on the service improvement plan?
- 05How are relatives involved when a person's risk assessment or care needs change?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried over from the previous comprehensive inspection published in 2020. This explanation was written from the published report of 21 May 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, November 2020
Rated Good; inspectors found safe, well-managed care, although some staff said they sometimes felt rushed.
This was an unannounced focused inspection on 8 October 2020. It followed concerns about cleanliness, staff behaviour and how management responded to concerns. The inspector spoke with people, relatives, staff and a health professional, observed care, and checked medicines, staffing, records and infection control.
The home was rated Good for Safe and Well-led. People said they felt safe and were treated well. Inspectors found enough staff, safe medicines support, suitable safeguarding systems and effective infection control measures during the Covid-19 pandemic.
The home had an experienced registered manager. Management investigated concerns, checked the quality of care and used these checks to plan improvements. Some staff said they sometimes felt rushed, and the manager was recruiting more staff and providing extra support.
This was not a full inspection of all five areas. Caring, Effective and Responsive were not inspected at this visit, so their previous ratings were carried forward. The overall rating remained Good, as it had at the previous inspection.
Infection control
The home had increased cleaning and infection control measures during the Covid-19 pandemic. Inspectors were assured that procedures covered visitors, testing, personal protective equipment and outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
People felt safe
People told inspectors they felt safe, and staff understood how to protect people from abuse and how to raise concerns.
“People told us they felt safe at Willowcroft.” from the report
Safe medicines support
Medicines were securely stored. Records were complete, and staff had been trained and checked to make sure they followed the correct procedures.
“Medicines administration records had been fully completed.” from the report
Strong management checks
The management team reviewed care, medicines, support plans and infection control. They also observed staff practice and used the results to plan improvements.
“The results of the various quality assurance checks were used to plan improvements to the service.” from the report
Some staff felt rushed
minorAlthough inspectors found enough staff to meet people's needs safely, some staff said they sometimes felt rushed. The manager was recruiting additional staff and providing extra support.
“Staff told us they were able to meet people's needs safely, although they sometimes felt rushed.” from the report
- 01Some staff said they sometimes felt rushed. What has changed since the inspection to reduce pressure on staff?
- 02Was the recruitment of additional staff completed, and are staffing levels still enough for people's needs?
- 03How are you checking that Covid-19 infection control procedures remain effective now?
- 04How are people and relatives currently involved in decisions about care and changes to the service?
- 05How often are risk assessments and support plans reviewed, particularly for people living with dementia?
This was a focused inspection of Safe and Well-led only; Caring, Effective and Responsive were not inspected and their previous ratings were used. This explanation was written from the published report of 5 November 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of OSJCT Willowcroft
4 rated inspections over 5 years: the service has held its Good rating throughout.
- May 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2020Goodstayed GoodSafe: GoodWell-led: Good
- August 2019Goodstayed GoodSafe: GoodWell-led: Good
- March 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- January 2014
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 16 November 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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