CQC report explained · a nursing home
What the CQC found at The Willows Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, April 2023
The Willows Care Home was rated Good; inspectors found safe, kind and well-managed care after checking concerns about staffing.
This was an unannounced focused inspection on 13 and 17 March 2023. Inspectors checked Safe and Well-led after receiving concerns about staffing. They spoke with people, relatives and staff, observed care, and reviewed care, medicine, recruitment and management records.
Inspectors found people were protected from abuse and avoidable harm. They found enough staff, safe recruitment, appropriate medicine systems and suitable infection control. Staff assessed risks, monitored people's health and involved other health professionals when needed.
The home was described as calm, friendly and person-centred. People and relatives said staff were kind and communication was effective. The overall rating stayed Good, as the other three question ratings were carried forward from the previous inspection in 2019.
Kind, person-centred care
Inspectors saw kind care and heard positive comments from people and relatives. Staff knew people and their families and supported personal relationships.
“We observed staff demonstrated kind, person centred care when interacting with people.” from the report
Staffing levels
The home had recently revised its rotas. People said staff responded promptly and there were enough staff to meet their needs.
“People confirmed they felt there was enough staff to meet their needs.” from the report
Safe medicines
Staff were trained and assessed as competent to give medicines. Inspectors found suitable arrangements for routine, as-required, tube-administered and covert medicines.
“Medicines were managed safely. Staff received medicines training and had their competency to safely administer medicines assessed.” from the report
Learning from incidents
Accidents and incidents were recorded, reviewed and analysed for patterns. The home used this information to reduce the chance of incidents happening again.
“A monthly analysis of all accidents and incidents was completed which allowed themes and trends to be identified so action could be taken to prevent reoccurrence.” from the report
Quality oversight
Managers completed regular audits and followed up actions. People, relatives and staff could share their views through meetings and surveys.
“The management team completed a range of monthly audits which supported oversight of key risk areas within the service.” from the report
No registered manager
needs fixingThere was no registered manager in post when inspectors visited. The manager had been in post for several months and had submitted an application to register.
“At the time of our inspection there was not a registered manager in post.” from the report
Annual leave decisions
minorOne staff member said a planned annual leave request had been refused without an explanation. The manager said some requests had been refused to maintain staffing levels.
“However, they said they had applied in advance to take annual leave, but it had been declined with no explanation given.” from the report
- 01Has the manager's application to register been completed, and who is currently legally responsible for the home?
- 02How have the revised staff rotas worked since the inspection, including at weekends?
- 03How are annual leave requests handled, and how are decisions explained to staff?
- 04How will you tell families when staffing levels or care arrangements change?
- 05What were the ratings for Effective, Caring and Responsive at the 2019 inspection, and what has changed since then?
This was an unannounced focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous inspection published on 18 June 2019. This explanation was written from the published report of 12 April 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, January 2022
Inspected but not rated; inspectors were assured that infection control arrangements were keeping people safe.
This was a targeted, announced inspection on 24 December 2021. It checked infection prevention and control because the home was being used for people discharged from hospital with positive COVID-19 results.
Inspectors found safe arrangements for visitors, testing, PPE, cleaning, isolation and staff working in the designated setting. They were also assured that people were admitted safely and that visits were being managed in line with current guidance.
The service was not given a rating. The inspection looked only at infection prevention and control, rather than the full range of care provided by the home.
Infection control
The home had arrangements to reduce the risk of infection spreading, including isolation, zoning, regular cleaning and updated policies.
“Isolation, co-horting and zoning were used to manage any potential spread of infection.” from the report
PPE and testing
There were plentiful supplies of PPE, testing for staff and people using the service, and checks on how PPE was used.
“There were plentiful supplies of personal protective equipment (PPE) throughout the designated setting” from the report
Dedicated staff arrangements
A dedicated staff group worked only in the designated setting while it remained open. Staff also had separate areas to change clothes.
“There was a dedicated staff group who would only work in the designated setting for the duration it remained open.” from the report
Staff training
Staff had completed infection control training and had received training in putting on and taking off PPE safely.
“All staff had completed training in relation to infection control, and recently received training about the correct use of PPE” from the report
Inspectors raised no specific concerns in this report.
- 01What is the home's latest full inspection rating, since this inspection was not rated?
- 02Are the dedicated staff group and separate clothing-change arrangements still in place?
- 03How are people admitted, isolated and supported if they have a positive COVID-19 result?
- 04How often are PPE use and infection control practices checked now?
- 05What arrangements are currently in place for visits?
This was a targeted inspection of infection prevention and control under the Safe question only; the service was inspected but not rated. This explanation was written from the published report of 1 January 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 Care Home
4 rated inspections over 8 years: the service has held its Good rating throughout.
- April 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2022Inspected but not ratedSafe: Inspected but not rated
- June 2019Goodstayed GoodSafe: GoodWell-led: Good
- May 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 21 January 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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