CQC report explained · a nursing home
What the CQC found at The Willows
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured that the home was preventing and managing infection, including through PPE, testing, cleaning, visitor checks and its layout.
- Effective?
- Good
- This question was not assessed in this targeted inspection.
- Caring?
- Good
- This question was not assessed in this targeted inspection.
- Responsive?
- Good
- This question was not assessed in this targeted inspection.
- Well-led?
- Good
- This question was not assessed in this targeted inspection.
What inspectors found, December 2020
Inspected but not rated; inspectors found good infection prevention and control arrangements.
This was a targeted inspection during the COVID-19 pandemic. Inspectors looked only at infection prevention and control measures because the home had been identified as a designated care setting for people discharged from hospital with a positive COVID-19 status.
Inspectors found good practice. The home used separate areas and staff teams for people discharged from hospital, had suitable personal protective equipment, carried out visitor checks, supported handwashing and testing, and increased cleaning in higher-risk areas.
The home was rated 'Inspected but not rated'. This means the visit did not give an overall quality rating or a full rating for all five areas of care. The Safe question was also inspected but not rated.
Separate areas for COVID-19 admissions
The home used a dedicated area and staff team for people discharged from hospital with COVID-19. Inspectors said this reduced the potential for infection to spread.
“This reduced the potential for the infection to spread.” from the report
PPE and infection controls
Supplies of masks, aprons, gloves, gowns and eye protection were available. Staff were observed using PPE appropriately, and the home also had handwashing, testing and increased cleaning arrangements.
“We were assured that this service met good infection prevention and control guidelines as a designated care setting.” from the report
Inspectors raised no specific concerns in this report.
- 01How are people admitted to the home safely now, including visitor health checks and hand disinfection?
- 02How do you separate people who may have COVID-19 or another infection from other residents?
- 03How do you make sure staff use the correct PPE and wash or sanitise their hands properly?
- 04How often are staff and residents tested, and what happens after a positive result?
- 05What are the home's current arrangements for cleaning higher-risk areas and managing infection outbreaks?
This was an announced targeted inspection of infection prevention and control only; the report did not rate the other four questions or give an overall quality rating. This explanation was written from the published report of 12 December 2020 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, November 2019
The Willows was rated Good overall; inspectors found kind, safe care, with some improvements needed around staffing, infection control and community access.
This was a planned, unannounced inspection on 3 October 2019. Inspectors observed care, spoke with people, relatives and staff, and checked care records, staffing, training, medicines and quality checks.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were protected from avoidable harm, received suitable care and food, and were treated with kindness, dignity and respect.
There were some shortfalls. Staff sickness was not always covered, infection control training and environmental checks needed attention, and people did not access the community independently. The provider was asked to improve these areas.
Risks and medicines
Risks were assessed when people moved in and reviewed regularly. Inspectors found that medicines were stored and given safely, with staff training and competency checks.
“Risks associated with people's care and support had been assessed when they had first moved into the service and were reviewed regularly.” from the report
Kind and respectful care
Inspectors saw staff treating people with kindness and compassion. People's privacy, dignity and involvement in care were generally respected.
“We observed people were treated with kindness and compassion by the staff group.” from the report
Personalised care plans
Care plans included people's personal needs, histories, likes and dislikes. Staff showed that they understood the people they supported.
“Care plans were detailed, included risk assessments and provided staff with information based on people's personal care needs.” from the report
Listening to people's views
The home used meetings and questionnaires to gather views from people, relatives and staff. Feedback had led to changes such as menu changes and trips.
“The registered manager sent us the outcomes from people, their relatives and staff questionnaires which provided the basis for changes in the home.” from the report
Staffing when people are absent
needs fixingStaff who were off sick were not always replaced, which made caring more difficult. Inspectors also heard concerns about delays to morning care and difficulty supporting some trips out.
“Staff felt there were usually enough staff on duty to support people, but if staff were sick, they were not always replaced making caring more difficult.” from the report
Infection control checks
needs fixingOne staff member could not fully recall infection control training. Inspectors recommended regular checks of the environment and planning any needed changes into refurbishment work.
“We recommend the environment of the home is regularly assessed and any changes to controlling infection are planned into the refurbishment programme.” from the report
Confidential information
needs fixingA clipboard containing people's confidential information was left in a public area. The provider had reminded staff to keep such information secure.
“However, we noted that a clipboard with people's personal confidential information was left in a public area.” from the report
Access to the community
needs fixingPeople took part in activities, but inspectors found that nobody accessed the community independently. The provider agreed to review people's abilities and encourage this where suitable.
“However, none of the people accessed the community independently.” from the report
- 01How do you make sure there are enough staff when someone calls in sick?
- 02What has changed to help people access the local community independently or with suitable support?
- 03How are infection control training and environmental checks monitored now?
- 04How do you keep care records and other confidential information secure?
- 05Have all staff completed the training that was still outstanding at the inspection?
This was an unannounced planned inspection of the whole care home and all five key questions; all five ratings remained Good from the previous inspection. This explanation was written from the published report of 2 November 2019 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
2 rated inspections over 3 years: the service has held its Good rating throughout.
- December 2020Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- November 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2016
Registered with the Care Quality Commission on 8 March 2016.
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 Leicestershire
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Most charge £980 to £1,260 a week. 82 can care for a couple. 12 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.”
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