CQC report explained · a residential care home
What the CQC found at The Willows Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found suitable staffing, safe recruitment, safe medicines handling, clean surroundings and risk assessments that staff followed.
- Effective?
- Good
- This question was not rated in this inspection.
- Caring?
- Good
- This question was not rated in this inspection.
- Responsive?
- Good
- This question was not rated in this inspection.
- Well-led?
- Good
- Inspectors found a positive and open culture, clear management arrangements and effective quality monitoring. People and staff were involved in decisions about the service.
What inspectors found, January 2024
The Willows Care Home was rated Good; inspectors found safe care and good management, with minor issues about window restrictors and medicines records.
This was an unannounced inspection on 09 January 2024. One CQC operations manager visited, spoke with people, staff and a health professional, observed care, and checked care plans, medicines records, recruitment files and management audits.
The home was rated Good for Safe and Well-led. Inspectors found people were protected from abuse, risks were assessed, medicines were generally handled safely, and there were enough suitably recruited staff. The home was clean and visitors could attend without restrictions.
Inspectors found some minor issues that the home's audits had not identified. Smaller windows needed restrictors, and some paper information about as-needed medicines and medicine patches was still being updated. The window restrictors were fitted the next day, and the medicines information was sent to inspectors after the visit.
Protection from harm
The home acted when there were safeguarding concerns, accidents or falls. Staff knew how to report suspected abuse.
“People were safeguarded from the risk of abuse and action was taken to mitigate the risk of harm to people following incidents and accidents.” from the report
Staffing
Inspectors found enough staff to meet people's needs safely. Recruitment checks followed appropriate procedures.
“People and staff, we spoke with told us there were enough staff to meet people's needs safely.” from the report
Medicines and cleanliness
Medicines were stored and administered safely during the visit. The home was clean and hygienic.
“We observed a trained member of staff administer people's prescribed medicines in a safe way.” from the report
Open management
Inspectors found a positive culture and a clear management structure. People were asked for their views about the service.
“There was a positive and open culture at the service.” from the report
Window restrictors
seriousSmaller envelope windows did not have restrictors when inspectors visited. This created a risk of someone falling from height, although restrictors were fitted the following day.
“although window restrictors had been fitted on all the larger windows, the smaller envelope windows required restrictors fitting.” from the report
Medicine information
needs fixingPaper protocols for as-needed medicines and body maps for medicine patches were still being updated because the electronic system could not store them. Copies were sent to inspectors after the inspection.
“PRN medicine (as required medicines) protocols and body maps for medicine patches were in the process of being updated in paper form” from the report
- 01Are the window restrictors now fitted to every applicable window, and how are they checked?
- 02How are as-needed medicine protocols stored, reviewed and made available to staff?
- 03How are body maps for medicine patches kept up to date now that the electronic system cannot store them?
- 04How do people and relatives give feedback, and how does the home act on it?
- 05What changes have been made since the previous Good rating published on 19 March 2018?
This inspection rated Safe and Well-led only; Effective, Caring and Responsive were not rated in this report. This explanation was written from the published report of 23 January 2024 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, March 2018
Rated Good; inspectors found safe, kind and personalised care, with no significant concerns identified.
Inspectors visited the home without notice on 27 February 2018. They observed care, spoke with nine residents, three relatives and staff, and checked care records, staff files and management records.
All five areas were rated Good: safe, effective, caring, responsive and well-led. Inspectors found enough staff, safe medicines systems, suitable training, kind care, activities and systems for handling complaints and improving quality.
The home was registered for 28 people and 21 people were living there at the inspection. Some residents were living with dementia. The overall Good rating was unchanged from the previous inspection on 1 March 2016.
Enough staff
Inspectors saw staff available to support people when needed. People said they did not have to wait for help.
“There were enough staff available to meet people's needs.” from the report
Food and health support
People were offered meal choices and alternatives. Nutrition risks were monitored, and people were supported to attend health appointments and receive referrals.
“People enjoyed the food and there was a choice available.” from the report
Respect and choice
Staff supported people in a kind way and promoted privacy and dignity. People were involved in decisions about their daily routines.
“People were encouraged to make choices about their daily routine.” from the report
Personalised activities
Staff knew people's preferences and offered a mixture of individual and group activities, including arts, crafts and puzzles.
“People were given the opportunity to participate in activities they enjoyed.” from the report
Quality checks
The manager and provider checked areas such as falls, medicines and call bell response times. An improvement plan was used when action was needed.
“Quality checks were completed by the registered manager and the provider.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you review risk assessments after falls or other incidents?
- 02How do you make sure staffing levels change when residents' needs change?
- 03How do you share learning from incidents with staff, while the incident learning work is still being developed?
- 04How are residents and relatives involved in decisions about activities, rooms and communal areas?
- 05How do you monitor whether complaints and informal concerns have been fully resolved?
This was an unannounced inspection of the overall service covering all five CQC questions; the Good ratings were unchanged from the previous inspection in 2016. This explanation was written from the published report of 20 March 2018 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
3 rated inspections over 8 years: the service has held its Good rating throughout.
- January 2024Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2018Goodstayed GoodSafe: GoodWell-led: Good
- March 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015
Registered with the Care Quality Commission on 20 April 2015.
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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