CQC report explained · a residential care home
What the CQC found at The Willows
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, July 2021
Inspected but not rated; the home's previous overall rating of Requires Improvement remained in place.
This was an unannounced, targeted inspection over four days in June 2021. Inspectors focused on how risks and restrictive practices were managed, and checked infection prevention and control.
Inspectors found personalised risk plans, safe medicines systems and enough staff on duty. They also found that the home relied heavily on agency staff, not all staff felt confident supporting distressed people, and the alarm system did not always work effectively.
Management systems had improved since the previous inspection. Communication and oversight were better, and relatives and staff were generally positive about the management team. However, the inspectors only looked at selected areas, so they did not give new ratings.
The overall rating therefore remained Requires Improvement. Safe and Well-led were recorded as inspected but not rated, rather than being reassessed fully.
Personalised risk planning
Risk assessments gave staff practical guidance about signs of distress and ways to reduce the chance of injury. Incidents and restrictive interventions were reviewed for learning.
“Risks were assessed, and plans were in place to mitigate risks, including distressed behaviours.” from the report
Medicines
Inspectors found that medicines were given at the right time. Staff had medicines training and their competence was checked.
“People received their medicines at the right time.” from the report
Infection control
The inspectors were assured about the home's arrangements for preventing and managing infections, including PPE, testing, visits and social distancing.
“We were assured that the provider's infection prevention and control policy was up to date.” from the report
Management oversight
The home had audits, data about incidents and other risks, and action plans with priorities and deadlines. Inspectors also found improvements in communication and oversight.
“There was a schedule of audits which included medication, infection prevention and control, the environment and quality.” from the report
Reliance on agency staff
needs fixingThe home had enough staff on duty, but depended on bank and agency workers. Staff and relatives said changes in staff could affect people who needed consistency.
“The service was dependent on agency staff to ensure that people received their commissioned hours.” from the report
Alarm system
seriousThe alarm used to request help did not always work effectively, and not all staff had access to it during the inspection. The provider said new equipment had been purchased.
“Staff expressed concerns about the effectiveness of alarm system in use to summon assistance and on the day of our inspection we observed not all staff had access to this.” from the report
Staff confidence with distressed behaviour
needs fixingNot all staff felt confident using some of the approaches for supporting people who were distressed. Further training was planned.
“Not all the staff we spoke to were confident in being able to support people who were distressed.” from the report
Variable record keeping
minorCare records were available, but staff were completing them to different standards. Senior staff were addressing the quality of recording.
“People's care records were accessible to staff and were being completed to varying degrees.” from the report
- 01Has the new alarm equipment been installed, tested and made available to every member of staff, including agency staff?
- 02How many permanent staff currently work in the home, and what is being done to reduce reliance on agency staff?
- 03What further training has been given to staff to support people who become distressed?
- 04How are managers checking that care records are completed consistently and accurately?
- 05How will the management team ensure that oversight of this home is not affected by responsibility for another service?
This was a targeted inspection of selected parts of Safe and Well-led, including risk management, restrictive practices and infection control; the other areas were not reviewed and the previous overall Requires Improvement rating remained. This explanation was written from the published report of 22 July 2021 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, September 2019
Rated Requires Improvement; inspectors found safe, kind care, but staff training, communication and meeting people's needs were not yet consistent.
This was an unannounced planned inspection on 7 August 2019. Inspectors spoke with people, relatives, staff, managers and other professionals. They observed care and checked care records, medicines records, recruitment files and management records.
The home was rated Good for Safe and Caring. Medicines were managed properly, safeguarding systems were in place, and staff were seen treating people with kindness, dignity and respect.
The home Requires Improvement for Effective, Responsive and Well-led. Staff training and supervision were not consistent, handovers and records were sometimes poor, and people did not always receive the health support, activities or continuity of care they needed. A new management team had started improvements, but these were not yet fully established.
Safe medicines support
Staff were trained and assessed as competent to give medicines. Audits checked that medicines were available, stored, given and recorded properly.
“Medicine audits were completed regularly and helped to ensure medicines were available as required, stored, administered, recorded, and disposed of as required.” from the report
Kind and respectful care
Inspectors observed positive interactions. People were supported with privacy, dignity, choice and independence where possible.
“We observed and received positive feedback about the way staff treated people.” from the report
Safeguarding
Staff understood abuse and how to report concerns. Families felt that concerns were acted on and that they were kept informed about risks.
“Families felt confident that staff acted upon any allegation or situation and kept them informed about any risk to their relative.” from the report
Improvement work had begun
The new management team had introduced stronger quality checks, an improvement plan and work to build more consistent staff teams.
“Governance arrangements were robust, and the service was stabilising.” from the report
Staff skills and training
needs fixingNot all staff had completed the training considered necessary, and staff practice had not been checked regularly enough. Agency staff did not always have the same specialist training or a recorded induction.
“Staff were not yet working effectively because staff performance and competencies had not been adequately reviewed over a period and not all staff had completed all training considered necessary.” from the report
Poor handovers and records
needs fixingImportant information was not always passed between staff. Daily notes and incident records did not consistently explain what had happened or what action was taken.
“We found staff handover was ineffectual and not all staff were given information which was important in terms of ensuring people received continuity of support across their day and risks were known to all staff.” from the report
Inconsistent support and activities
needs fixingPeople did not always receive the health care, personal care support, community activities or preferred staff support they needed. Inspectors found this had improved but had not been consistent over the previous year.
“Some people had not been sufficiently supported with their health care needs, behaviours or been able to access social activities when they wanted to.” from the report
Environment and equipment
minorSome areas needed redecoration or repair. Inspectors noted concerns about gardens, laundry facilities, wear and tear and damaged equipment.
“Both staff and relatives raised concerns about the overgrown gardens, the laundry facilities as well the building being damaged or showing signs of wear and tear.” from the report
End of life planning
minorNo one was receiving end of life care during the inspection, but care plans did not contain end of life information. The manager accepted that this needed to be addressed.
“Care plans were good and described what was important to the person and including their preferences and preferred support, but nothing was recorded about end of life.” from the report
- 01How many regular staff now support my relative, and how much is the home currently relying on agency staff?
- 02Have all staff, including agency staff, completed the specialist training needed to support people during distress or restraint?
- 03How do you make sure important information is handed over between shifts and recorded clearly?
- 04How will you ensure my relative receives timely health care, personal care support and the activities they prefer?
- 05What improvements have been completed to the building, gardens, laundry facilities and damaged equipment?
This was an unannounced planned inspection that looked at all five CQC questions and both the premises and care provided; Safe and Caring remained Good, while Effective, Responsive and Well-led fell from Good to Requires Improvement. This explanation was written from the published report of 26 September 2019 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 The Willows
3 rated inspections over 4 years: the service has held its Requires improvement rating throughout.
- July 2021Inspected but not ratedcurrent ratingSafe: Inspected but not ratedWell-led: Inspected but not rated
- September 2019Requires improvementdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2016Requires improvementSafe: GoodEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 21 December 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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13 live-in carers within about an hour of Norfolk
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Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
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