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.
- Safe?
- Requires improvement
- Inspectors found that safeguarding processes were not always followed, infection control was not always safe and recruitment checks were incomplete. Staffing levels, risk assessments, fire safety and medicine records had improved.
- Effective?
- Good
- Care plans, staff training and support had improved. People were supported with food, weight monitoring, healthcare and decisions about their care.
- Caring?
- Good
- The report does not give a separate rating for Caring. People and relatives said they were happy with the care, and staff were described as friendly and supportive.
- Responsive?
- Good
- The report does not give a separate rating for Responsive. It says care plans had improved and were reviewed, but some records did not give staff enough information to provide consistent care.
- Well-led?
- Requires improvement
- Management oversight was inconsistent. Quality checks did not identify safeguarding, infection control and record-keeping concerns, and some incidents were not notified to the CQC as required.
What inspectors found, May 2023
Rated Requires Improvement and no longer in special measures; inspectors found better care planning and staffing, but serious safeguarding and management concerns remained.
This was an unannounced follow-up inspection on 15 March 2023. Inspectors spoke with people living in the home, relatives and staff. They observed care, checked the environment and reviewed care records, medicine records and management documents.
The home had improved from its previous Inadequate rating. Safe and Well-led were rated Requires Improvement, while Effective was rated Good. Inspectors found enough staff, better training, improved care plans and mostly safe medicine records.
However, people were not always protected when safeguarding concerns were found. Infection control was not always safe, records were not always accurate, and quality checks had failed to identify important problems. The home remained in breach of several regulations, but it was no longer in special measures.
Improved care planning
Care plans and risk assessments had been updated to reflect people's different needs. Reviews recorded changes more clearly.
“Care plans and risk assessments had been updated and reflected peoples diverse needs.” from the report
Enough staff
Inspectors found enough staff to meet people's needs. Staffing was no longer a breach of regulations.
“There were enough staff to meet people's needs.” from the report
Staff training and support
Training was up to date and staff said they felt supported in their roles.
“Staff training was completed and up to date.” from the report
Healthcare and consent
Staff contacted health professionals when people's needs changed and followed professional advice. The home was also working within the principles of the Mental Capacity Act.
“Records showed that staff contacted health professionals in a timely manner where people's health needs changed.” from the report
Positive experiences
People and relatives were happy with the care and reported improvements to the home. Staff were described as friendly and welcoming.
“People and their relatives were happy with the care and support received.” from the report
Safeguarding failures
seriousThe provider did not always protect people when abuse concerns were identified. Inspectors made two safeguarding referrals to the local authority after the inspection.
“The provider continued to fail to protect people from abuse.” from the report
Infection control
seriousSome areas smelled unpleasant, furniture could not be cleaned effectively, PPE was stored unsafely and there were not enough clinical waste bins.
“A failure to ensure effective Infection Prevention Control measures were in place is a breach of Regulation 12” from the report
Inaccurate care records
needs fixingRecords about people's health and wellbeing were not always completed accurately. Positional changes were not always recorded clearly enough for staff to know when the next change was due.
“Records relating to people's health and wellbeing were not always completed accurately to reflect care given or future care needs.” from the report
Weak management oversight
needs fixingThe provider's quality systems failed to identify problems found during the inspection. The home had been rated Requires Improvement for eight consecutive inspections.
“The consistent change in management and lack of oversight from the provider has resulted in the service been rated requires improvement for 8 consecutive inspections.” from the report
Recruitment checks
needs fixingA reference raised concerns about a staff member's honesty and integrity, but the management team had not taken action. The CQC recommended a review of recruitment practices.
“Recruitment checks were not always completed thoroughly to ensure new staff were suitable to work with vulnerable people.” from the report
- 01What action has been taken after the two safeguarding referrals made by inspectors?
- 02How have you improved the process for reporting and investigating safeguarding concerns?
- 03What has been done to provide clinical waste bins, store PPE safely and remove unpleasant smells?
- 04How are care records, including records of positional changes, now checked for accuracy?
- 05Who is currently providing management oversight, and how is progress on the CQC action plan being monitored?
This was an unannounced follow-up inspection after the previous Inadequate rating, with detailed findings under Safe, Effective and Well-led; the report says ratings for any key questions not inspected carried over from the previous inspection. This explanation was written from the published report of 16 May 2023 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, December 2022
The Willows remains Inadequate and in special measures; inspectors found people at risk because of unsafe care, poor staffing and weak management.
Inspectors visited on 13 and 14 September 2022. The first day was unannounced. They spoke with five people and staff, and checked care plans, medicines records and management records.
The home was not safe. Risk assessments did not contain important information, safeguarding procedures were not followed, and there were not enough staff at times. Medicines management had improved, but some records and checks were still unreliable.
The home was rated Requires Improvement for Effective. Some staff training and supervision had started, but care planning, health monitoring, refurbishment and dementia training were still not good enough.
The home was rated Inadequate overall and for Safe and Well-led. This was the seventh consecutive inspection rated below Good and the third rated Inadequate. The home remains in special measures.
Some medicines improvement
Medication errors had reduced, and records for covert and as-needed medicines had improved. The home was no longer in breach of the medicines part of Regulation 12.
“There had been a reduction in the number of medication errors made within the service.” from the report
New manager starting changes
The new manager had begun staff supervision, appraisals and competency assessments. Some additional staff training had also been completed.
“The new registered manager had recently started staff supervisions.” from the report
Consent processes
Inspectors found systems for overseeing DoLS applications, and decisions were recorded in line with Mental Capacity Act principles.
“Decisions had been recorded in line with MCA principles.” from the report
Infection control arrangements
Inspectors were assured about several infection control arrangements, including visitors, admissions, infection outbreaks and the infection prevention policy.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Recruitment checks
The records reviewed showed that recruitment checks were in place. One missing interview record was supplied after the inspection.
“Recruitment checks were in place.” from the report
People at risk from poor risk assessments
seriousCare plans and risk assessments did not reflect important health conditions or behaviours. Inspectors also found an unaddressed scalding risk and security risks.
“Care plans and risk assessments continued to not reflect people's individual health conditions or risks associated with specific behaviour.” from the report
Not enough staff
seriousThere were periods when people were left unattended in communal areas. Staff also had to do cooking and cleaning, reducing the time available to support people.
“There was insufficient staff on duty to keep people safe and meet people's needs.” from the report
Weak oversight and records
seriousAudits did not identify all the problems inspectors found. Medicines records, handovers, daily notes and monitoring charts were not sufficiently detailed.
“The quality of accurate and contemporaneous records remained poor.” from the report
Health monitoring and training gaps
needs fixingFluid and bowel monitoring was not always completed properly. Dementia training was incomplete, and the provider was asked to monitor supervision, appraisals and training.
“Only seven out of 15 staff on the training matrix had completed training in dementia.” from the report
Overdue repairs and unanswered feedback
needs fixingSome flooring, carpets, furniture and a garden handrail needed attention. Suggestions from people had not always been acted on.
“Some areas of the home continued to require refurbishment.” from the report
- 01What has been done to make sure every person's health conditions, behaviours and risks are clearly recorded and understood by staff?
- 02How many staff are now on duty at each time of day, and how will people be kept supervised when staff are cooking or cleaning?
- 03What action has been taken after safeguarding incidents, and how is the safeguarding log now checked?
- 04How are medicines stock, administration records and returned medicines checked each day?
- 05Which repairs and refurbishment work have been completed, and what is the timetable for any remaining work?
This was a follow-up inspection after the previous Inadequate rating, with infection prevention and control also checked; ratings for any key questions not inspected carried over from the last inspection. This explanation was written from the published report of 1 December 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.
Every inspection of The Willows
8 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- May 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2022Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementWell-led: Inadequate
- May 2022Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementWell-led: Inadequate
- May 2022Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementWell-led: Inadequate
- May 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- March 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2015Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- August 2011
Registered with the Care Quality Commission on 18 August 2011.
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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32 live-in carers within about an hour of North Lincolnshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,300 a week. 29 can care for a couple. 11 years' experience on average.
“What truly stands out is how mindful and attentive she is to all of my medical needs, always going above and beyond to ensure I’m comfortable and well cared for.”
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.