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.
What inspectors found, March 2024
Rated Requires Improvement; inspectors found some safer care improvements but ongoing issues with records and management oversight.
Inspectors visited The Willows care home unannounced on 5 September 2023 to check on safety and leadership. They spoke with residents, staff, and reviewed records and policies.
The home had made some progress since the last inspection, especially in assessing risks and managing medicines. However, some records were unclear or incomplete, such as those for medicines, fire safety plans, and food and fluid intake.
People said they felt safe and staff were kind, but some care plans lacked detail to ensure personalised support. The home had enough staff and followed safe recruitment practices.
The management had improved governance systems but these were still not fully effective. Some audits missed problems, and staff were unclear about emergency plans. The home was no longer in special measures but still rated Requires Improvement.
Staffing levels
There were enough staff to meet people's needs and recruitment checks were safely carried out.
“Now there are more staff we have more time with the residents. We are not rushed.” from the report
People felt safe
Residents told inspectors they felt safe living at the home and staff were attentive to their needs.
“It's very good. It's very friendly. There's always someone around and I'm not wanting for anything.” from the report
Infection control
The home managed infection prevention well and had up to date policies to reduce risks.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Care plans lacked detail
needs fixingSome care plans did not give enough information for staff to provide personalised and consistent support.
“Some care plans lacked the information that staff needed to provide personalised and safe care.” from the report
- 01How does the home ensure medicines are always recorded accurately and safely managed?
- 02What steps are in place to keep fire evacuation plans up to date and staff informed?
- 03How does the home make sure care plans have enough detail to meet individual needs?
- 04What activities and emotional support are available to help residents feel engaged and connected?
- 05How does management check and improve the quality and safety of care regularly?
This was a focused inspection of Safe and Well-led only; the other ratings carry over from the last inspection. This explanation was written from the published report of 29 March 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 2023
Requires Improvement and in special measures; inspectors found unsafe risk and medicines management and inadequate oversight.
This was an unannounced focused inspection on 23 November 2022. Two inspectors spoke with people, relatives, staff and the provider. They observed care and reviewed care records, medicines records, staff files and management records.
The overall rating was Requires Improvement. Safe was Requires Improvement and Well-led was Inadequate. Inspectors found risks were not always clearly assessed or managed, medicines were not always given as prescribed, and checks by the provider did not identify important problems.
There were some positives. People said they felt safe, staffing levels met people's needs, recruitment checks had been completed and infection control had improved in some areas. People and relatives made positive comments about staff, although views about the service were mixed.
The home was placed in special measures because an Inadequate rating had been found in a key question over two consecutive comprehensive inspections. The provider remained in breach of regulations, registration conditions remained in place and CQC said it would re-inspect within six months if registration was not cancelled.
Enough staff
Inspectors found enough staff were available to meet people's needs. Recruitment checks had also been completed.
“There were enough staff available to support people's needs and staff had been recruited safely.” from the report
Positive staff comments
People and relatives gave some positive feedback about staff, although their views of the service were mixed.
“The care is adequate, the girls all seem to be caring.” from the report
Some infection control progress
Inspectors found improvement in infection prevention and control and were assured about several infection-related arrangements.
“We were assured that the provider was responding effectively to risks and signs of infection.” from the report
Support with decisions
Staff recognised when people needed help to make decisions. The report said the service was working within the principles of the Mental Capacity Act.
“Staff recognised where people needed support to make decisions.” from the report
Risks were not managed consistently
seriousCare records did not always explain clearly how risks should be managed. Inspectors found concerns about falls, pain, nutrition and behaviours that could cause harm.
“Risks continued not to be identified, monitored and managed effectively.” from the report
Medicines problems
seriousInstructions for medicines were not always followed. Audits also failed to identify discrepancies, meaning one person may not have received medicine as prescribed.
“Prescribing instructions were not always followed.” from the report
Weak provider oversight
seriousThe provider's audits and reports did not identify or correct repeated problems. This was the fifth time the provider had breached Regulation 17.
“Systems and processes to assess and monitor the safety and quality of the service remained ineffective.” from the report
Incomplete incident learning
needs fixingAccident and incident records were not kept in a central system that could show patterns, referrals or lessons to prevent repeated harm.
“The provider did not have a clear system in place to analyse accidents and incidents.” from the report
Privacy and care records
needs fixingToilet doors did not have working locks, and not all staff could access or use people's care records. This could affect privacy and safe, personalised care.
“There were no working locks fitted to toilet doors to ensure people's right to privacy was respected.” from the report
- 01What has changed since the inspection to make sure each person's risks, including falls, pain, nutrition and behaviours, are clearly recorded and managed?
- 02How do you now check that medicines are given exactly as prescribed and that medicine discrepancies are found quickly?
- 03Have all fire risks, including wedged-open bedroom doors, been fixed and checked regularly?
- 04How are accidents and incidents now recorded, analysed and used to prevent repeated harm?
- 05How can temporary and permanent staff access and understand each person's current care records?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from the last inspection. This explanation was written from the published report of 16 March 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.
Every inspection of The Willows
6 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- March 2024Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2023Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Inadequate
- May 2022Requires improvementup from InadequateSafe: Requires improvementWell-led: Inadequate
- July 2021Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
- February 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- February 2019Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2018
Registered with the Care Quality Commission on 9 January 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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What to check when you visit
At least 100 live-in carers within about an hour of Coventry
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 £950 to £1,260 a week. 80 can care for a couple. 11 years' experience on average.
“If you bump into her in the night on her way to the bathroom she will still inquire how you are and if everything is alright.”
“My mum would not eat, drink, bath nor sleep without her. In short, she was FAMILY and we loved her dearly”
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.