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.
What inspectors found, April 2023
Rated Requires Improvement; inspectors found kind and safe day-to-day care, but recruitment and management checks were not reliable.
This was an unannounced focused inspection on 27 February 2023. Two inspectors spoke with people, a relative and staff, and checked care, medicine, recruitment, training, rota and audit records.
People said they felt safe and supported. Staff knew how to recognise and report abuse. There were enough staff, medicines were managed safely, risks were recorded and reviewed, and infection control arrangements were suitable.
However, recruitment checks were incomplete. One member of staff had only a basic DBS check, and risks linked to previous convictions had not been clearly assessed. The home's checks did not reliably identify these problems or some window safety issues.
The overall rating stayed Requires Improvement, as did Safe and Well-led. The inspection only assessed those two areas. The provider had improved staffing, risk assessments and medicines arrangements, but remained in breach of good governance and was also found in breach of recruitment requirements.
Enough staff
Inspectors found enough staff to meet people's needs. People said staff responded promptly and were visible around the home.
“People's requests for staff support were responded to promptly.” from the report
Better risk management
Care records described people's risks and how staff should reduce them. Staff understood individual needs, including dietary and falls risks.
“People's care records detailed their individual risks, how these had been minimised and how staff were to support the person in line with best practice.” from the report
Safe medicines
Medicines were stored securely and people received them as prescribed. This was an improvement from the previous inspection.
“At this inspection, people's medicines were stored securely.” from the report
People felt safe
People told inspectors they felt safe with staff. Staff understood different types of abuse and how to report concerns.
“All people we spoke with told us they continued to feel safe with the staff who supported them.” from the report
People's views heard
People could share their views through conversations, meetings and surveys. People knew the manager and deputy manager.
“People were supported to have their views listened to through one-to-one conversations, resident meetings and surveys.” from the report
Incomplete recruitment checks
seriousSome staff files were missing required work or qualification information. One staff member had a basic rather than enhanced DBS check, and a previous conviction had no clear risk-management record.
“Recruitment procedures were not established or operated effectively to ensure staff employed met the conditions.” from the report
Weak management checks
seriousThe home's audit systems did not reliably find recruitment problems or environmental safety concerns. The provider remained in breach of good governance requirements.
“Governance systems had not been established to assess, monitor and improve the service provision” from the report
Window safety issue
needs fixingSome windows were still not restricted in line with the relevant standards. They were locked, which reduced the risk of falling, but did not allow adequate ventilation.
“At this inspection, we found some windows continued to not be restricted in line with the Health and Safety Executive Standards (HSE).” from the report
- 01Have all staff files now been checked for previous employment and qualification information?
- 02Does every staff member who needs one now have an enhanced DBS check, and how are any disclosed risks reviewed and managed?
- 03Have window restrictors been fitted and checked so windows provide adequate ventilation without creating a safety risk?
- 04How often are recruitment, care records and environmental checks now audited, and who independently reviews the results?
- 05What progress has been made on the action plan requested by the CQC after this inspection?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from the previous inspection when calculating the overall rating. This explanation was written from the published report of 22 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, May 2022
Rated Requires Improvement; inspectors found people felt safe and supported, but there were serious gaps in risk management, staffing and leadership.
This was an unannounced focused inspection on 7 March 2022. Two inspectors spoke with people, staff, the registered manager and the provider. They observed care and checked care, medicine, staffing, training and management records.
People said they felt safe and supported. Staff were visible, answered call bells promptly and people received their medicines when they should. However, risk assessments and care records were not always complete or up to date. Staff did not always know about people's individual risks, and falls were not consistently recorded or followed up safely.
There were not enough staff with the right mix of skills. Staff and the registered manager were also doing cooking and cleaning, which reduced time for care, hobbies, management work and record keeping. Infection control practices were not always followed, including mask use and hand and arm hygiene.
The overall rating was Requires Improvement, as were Safe and Well-led. The inspection found breaches of regulations about safe care, staffing and good governance. Warning notices were issued for safe care and good governance, and the provider was asked for an action plan.
People felt safe
Everyone spoken with said they felt safe with the staff supporting them. A relative also said their family member was protected from abuse.
“All people we spoke with told us they continued to feel safe by the staff who supported them.” from the report
Staff were visible
People said staff were present and responded promptly to call bells. Inspectors also saw staff checking regularly on people who preferred to stay in their rooms.
“People confirmed there were staff visible, and prompt to answer call bells.” from the report
Teamwork
Staff said they worked well together and wanted the home to improve. Inspectors saw staff working hard to support people.
“Staff told us they worked together well as a team.” from the report
Medicines usually given on time
Inspectors found people received their medicines when they should. One person said staff checked whether they were in pain and needed medicine.
“People received their medicines when they should. One person told us how staff always checked if they were in pain and needed any medicine to help with this.” from the report
Risks were not managed consistently
seriousRisk assessments were missing, incomplete or out of date. Staff did not always know about individual risks, and falls involving head injuries were not always followed up in line with the home's policy.
“Systems had not been established to assess, monitor and mitigate risks to the health, safety and welfare of people using the service.” from the report
Not enough staff with the right skills
seriousThere was not always a sufficient skill mix. Care staff and the registered manager also covered cooking and cleaning, reducing time for care, activities and management work.
“There was not always a sufficient skill mix of staff working in the home.” from the report
Weak quality checks
seriousThe provider's checks had not identified ongoing concerns or driven improvement. This was the second consecutive inspection where these systems were found to be ineffective.
“This is the second consecutive inspection where the effectiveness of the provider's systems to monitor the quality of service had failed to identify concerns and drive improvements.” from the report
Care information was difficult to use
needs fixingSome paper records were out of date and difficult to find. More current online records were kept in the registered manager's office, creating a risk that staff would miss important information.
“The paper records held in the main office were out of date and in no particular order, or easy to reference.” from the report
Training and infection control gaps
needs fixingSome training was incomplete or out of date. Inspectors also saw masks worn incorrectly, jewellery below the elbow and an unclean shower chair.
“We were not always assured that the provider was using PPE effectively and safely.” from the report
Medicines storage
needs fixingPeople received medicines on time, but medicines were not always stored securely. The registered manager said this would be reviewed immediately.
“Our inspection identified that medicines were not always stored securely. The registered manager advised they would review this immediately.” from the report
- 01What has been done to make sure every resident has a complete and up-to-date risk assessment?
- 02How are falls, including head injuries, now recorded, medically reviewed and monitored?
- 03What is the current staffing mix, and how will you make sure care staff are not regularly taken away from care to cook or clean?
- 04Which staff training was incomplete or out of date, and has it now been completed?
- 05Where can staff find the most current care information, and how do you check they have read and understood it?
This was a focused inspection of Safe and Well-led, prompted by concerns about staffing and training; the other key question ratings and the overall rating were carried over from the previous inspection. This explanation was written from the published report of 4 May 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 4 years: the service has slipped, from Good to Requires improvement.
- April 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- January 2022Requires improvementSafe: Requires improvementWell-led: Requires improvement
- February 2021Inspected but not ratedSafe: Inspected but not rated
- March 2019GoodSafe: GoodWell-led: Good
- June 2018
Registered with the Care Quality Commission on 22 June 2018.
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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At least 100 live-in carers within about an hour of Worcestershire
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 £1,260 a week. 85 can care for a couple. 9 years' experience on average.
“I have never met a person who is so kind and thinks about others before himself to such an extent as Chris Malagala.”
“She was very caring, kind and patient to all his needs, she built up a wondetful rapport with him, she was dedicated and was there for him through good times as well as through the tough times”
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.