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
- Risk assessments and medicines management had improved and were generally safe. However, staffing was below the identified level, people sometimes waited for care, and some infection control practices increased risk.
- Effective?
- Requires improvement
- People were assessed, supported to access healthcare and helped to eat safely. Fluid records and staff training records were incomplete, and parts of the building needed updating.
- Caring?
- Requires improvement
- Staff were kind and caring, but people did not always receive personalised care or choices. Inspectors also found that privacy was not always respected.
- Responsive?
- Requires improvement
- Care plans mostly reflected people's needs, but guidance for supporting distressed people living with dementia was not always clear. Activities were lacking and care staff provided them only when they had time.
- Well-led?
- Requires improvement
- Managers were approachable and acted on complaints, incidents and feedback. However, quality audits had not identified all the concerns found during the inspection.
What inspectors found, July 2022
Requires Improvement; inspectors found kind staff and safer medicines, but staffing, activities, privacy and infection control needed improvement.
This was an unannounced inspection on 27 April 2022. Two inspectors spoke with people, staff and managers, observed care, reviewed six care plans, medicines records and quality audits, and checked infection control.
The home identified risks and managed medicines safely. People were supported with eating, healthcare and decisions about their care. Staff were described as kind, and people said they felt safe.
However, staffing was below the level the manager had identified as necessary. People sometimes waited for care, people living with dementia were not always supported when distressed, and there was little time for activities. Inspectors also found incomplete fluid records, gaps in training records, infection control concerns, limited choices, and privacy concerns.
All five areas were rated Requires Improvement. The home had improved since the 2019 inspection and was no longer in breach of regulations, but it had remained Requires Improvement for two consecutive inspections.
Medicines
Medicines were stored, administered and recorded safely. Staff gave people time to take medicines calmly.
“Medicines were safely administered in line with people's prescriptions.” from the report
Risk management
Risks were assessed and care plans described the equipment and support people needed. Emergency evacuation plans were also in place.
“Risks to people were identified assessed and action taken to keep people safe.” from the report
Kind staff
People described staff as kind and caring. Staff supported people with eating and spent time talking with them.
“The registered manager and staff were kind and caring.” from the report
Safeguarding
Staff knew how to report safeguarding concerns, including to outside agencies. The manager worked with the local authority when concerns were investigated.
“Staff were aware of how to raise concerns with the registered manager and how to escalate them to the provider if needed.” from the report
Healthcare support
Records showed that people were supported to access healthcare when needed. Staff worked with health and social care professionals.
“Records showed that people had been supported to access healthcare whenever needed.” from the report
Staffing and waiting
seriousThe home was not staffed to the level the manager had identified. People sometimes waited for care, and staff had less time for individual support.
“While people's needs were met, understaffing meant at times some staff were focused on the tasks they needed to complete, and care was not centred around individual needs.” from the report
Infection control
seriousAn unfinished bathroom conversion and the storage of cleaning equipment increased infection risks. Mattress covers had not been checked since December 2021.
“This had not been fully completed and the way it was being used increased the risk of infection.” from the report
Activities and choice
needs fixingActivities were limited because there was no dedicated activities coordinator. People were not always offered choices, including at lunchtime.
“There was no dedicated activities coordinator and activities were provided by care staff in between their other duties if they had time.” from the report
Privacy and the environment
needs fixingPeople said staff did not always knock before entering rooms, and other residents could enter at inappropriate times. Some areas were tired, with stained carpets and uneven flooring.
“People told us that staff were not always respectful of their privacy.” from the report
Records and oversight
needs fixingFluid intake records and training records were incomplete or out of date. Quality audits had not identified all the problems found by inspectors.
“However, the audits did fall short in identifying some of the concerns we found.” from the report
- 01What staffing levels are in place now, and how do you prevent people having to wait for care?
- 02What clear guidance do staff now have for supporting people living with dementia when they become distressed?
- 03What activities are available each week, and who is responsible for providing them?
- 04What has been done to complete the sluice room, store cleaning equipment safely and check mattress covers?
- 05How do you protect people's privacy and offer choices about meals and daily care?
This was an unannounced inspection covering all five key questions, including infection prevention and control; the home was a care home without nursing care. This explanation was written from the published report of 1 July 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, February 2022
Inspected but not rated; inspectors found good infection control arrangements and no reported shortfalls.
This was an unannounced, targeted inspection. It followed concerns about infection prevention and control, and also considered whether COVID-19-related staffing pressures affected the home.
Inspectors said they were assured that the home used PPE safely, supported testing, managed visitors and admissions safely, and kept its infection control policy up to date. They also found the environment clean and hygienic.
Staff and residents had received COVID-19 vaccinations and took part in testing. The home checked the vaccination status of visiting professionals and was meeting the requirement for non-exempt staff and visiting professionals to be vaccinated.
The home was inspected but not rated. This report therefore does not give a rating such as Good or Requires Improvement for the overall service.
Infection control
Inspectors were assured that the home had arrangements to prevent and manage infections, including safe use of PPE, testing and visits.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Vaccination and testing
Staff and residents had received COVID-19 vaccinations and took part in a testing programme. The home also checked visiting professionals.
“Staff and people living at the home had received their COVID-19 vaccinations and took part in a testing programme.” from the report
Clean environment
Inspectors found the premises clean and said the layout and hygiene practices promoted safety.
“We were assured that the provider was promoting safety through the layout and hygiene practices of the premises.” from the report
Inspectors raised no specific concerns in this report.
- 01How are you checking the vaccination status of staff and visiting professionals now?
- 02How are current staffing pressures affecting care and daily life in the home?
- 03How are PPE use and testing being monitored for staff and residents?
- 04How are visits being facilitated under the current guidance?
- 05What arrangements are in place to prevent or manage an infection outbreak?
This was an unannounced targeted inspection of infection prevention and control, with questions about staffing pressures; the other areas were not rated, and the report gives inconsistent years for the inspection date. This explanation was written from the published report of 8 February 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
4 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- July 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2022Inspected but not ratedSafe: Inspected but not rated
- August 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- December 2016Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- April 2011
Registered with the Care Quality Commission on 6 April 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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9 live-in carers within about an hour of 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.
8 can care for a couple. 10 years' experience on average.
“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.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
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