CQC report explained · a nursing home
What the CQC found at The Willows Nursing and Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found suitable risk assessments, safe medicines systems, appropriate recruitment checks and enough staff to meet assessed needs during the visit. They also found infection control arrangements and systems for learning from accidents and incidents.
- Effective?
- Requires improvement
- The building had chipped paintwork, damaged woodwork, worn flooring and other maintenance issues. Staff training was up to date, but some staff said they had not received formal supervision or appraisals.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward, but that rating is not stated in this report.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward, but that rating is not stated in this report.
- Well-led?
- Good
- Inspectors found effective quality audits, open management and good involvement of people, relatives, staff and outside professionals. An action plan was produced for the environmental work.
What inspectors found, April 2023
The Willows Nursing and Residential Home is rated Good; inspectors found safe care and good leadership, but the building and some staff support needed improvement.
This was an unannounced, focused inspection on 15 March 2023. Two inspectors and a nurse specialist adviser spoke with people, relatives, staff, a visiting professional and the manager. They also checked care plans, risk assessments, recruitment files, medicines records and environmental audits.
The home was rated Good for Safe and Well-led. Inspectors found suitable risk assessments, safe medicines practice, appropriate recruitment checks, enough staff during the visit and systems for investigating incidents. People had access to healthcare, enjoyed the food and were supported to make choices.
Effective was rated Requires Improvement. Several parts of the building were tired and needed repair or redecoration, and some staff said they had not received formal supervision or appraisals. The home produced an action plan after the inspection. The overall rating improved from Requires Improvement to Good, but Caring and Responsive were not inspected during this visit and their previous ratings were carried forward.
Safe medicines
Medicines were stored and given safely. Only trained staff administered them, and records showed people received medicines as prescribed.
“Medicines were administered only by staff who were trained to do so, and records showed that staff supported people with their medicines as prescribed.” from the report
Risk management
Risk assessments covered areas such as mobility, health and smoking. Window restrictors were changed immediately when inspectors raised a concern about their fixings.
“The registered manager immediately ensured that tamper proof screws were installed on these restrictors.” from the report
Food and healthcare
People enjoyed the food and had their dietary needs, preferences and monitoring recorded when needed. Inspectors found that people received the healthcare support they required.
“People enjoyed the food on offer and were supported well in this area.” from the report
Open leadership
People and relatives said the home was open and well run. The home worked with healthcare professionals and other agencies.
“The registered manager and staff team were open and honest during our inspection and were receptive to any feedback we gave.” from the report
Building maintenance
needs fixingSeveral areas were tired and needed repair or redecoration, including damaged surfaces, worn flooring and blown double glazing. These issues had been identified, but prompt action had not been taken before the inspection.
“There were many areas of the service which were tired and in need of re decoration or maintenance.” from the report
Staff supervision
needs fixingSome staff said they had not had formal supervision or appraisal opportunities. The manager said the formal supervision process would be reviewed.
“Whilst most staff felt generally supported, some said they did not have any formal supervision or appraisal opportunities.” from the report
Staffing feedback
minorStaffing matched assessed needs during the inspection, but some people and a staff member felt staffing levels could be improved. Inspectors found no evidence of harm from staffing levels.
“Some people we spoke with felt that staffing levels could be improved upon.” from the report
- 01Which repairs and redecoration in the environmental action plan have now been completed, and what remains outstanding?
- 02How are you checking that environmental problems are dealt with promptly?
- 03How often do staff now receive formal supervision and appraisals?
- 04What staffing levels are planned for the times when the home is spread out or people need more help?
- 05What were the previous ratings for Caring and Responsive, and what has changed in those areas since the last full inspection?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 7 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, September 2022
Rated Requires Improvement; inspectors found risks in the building, medicines records and quality checks, although people received kind care and prompt health support.
This was an unannounced, focused inspection on 1 August 2022. Inspectors looked at Safe, Effective and Well-led after concerns about moving and handling, staffing, nutrition and skincare. They spoke with people, a relative, staff and health professionals, observed care and checked care, medicine, recruitment and management records.
The home was not always safe. Inspectors found risks from an unrestricted upper-floor window, unsecured furniture and hazardous products. Smoking arrangements were not safely checked, and one person who needed supervision was not supervised. Some medicine records were incomplete. Cleaning and staff refresher training also needed improvement.
There were positive findings. Staff knew people well, treated them kindly and supported their choices. People received suitable food and drinks, medicines were usually given on time, and staff sought medical advice promptly when health worsened. However, checks by managers did not reliably identify or act on problems.
The overall rating fell from Good at the previous inspection, published in May 2019, to Requires Improvement. The report says the home breached Regulation 12 on safe care and treatment and Regulation 17 on good governance. The provider was asked for an action plan and CQC said it would monitor progress with the local authority.
Kind, personalised care
Staff knew people's preferences and how they wanted their care delivered. Inspectors observed kind interactions and people said staff were respectful.
“The registered manager and staff team were passionate about providing person centred care and improving people's health outcomes.” from the report
Food and drinks
Staff knew people's dietary needs and offered choices. Inspectors saw people eating well and having drinks available.
“People were supported to eat and drink enough by staff that knew their dietary requirements, preferences and wishes.” from the report
Prompt healthcare
Staff sought medical advice when people's health deteriorated. Healthcare professionals' advice was reflected in care plans and risk assessments.
“Records showed that when people's health deteriorated prompt action was taken to seek medical advice and referrals were made to other healthcare professionals to reduce the risk of further deterioration.” from the report
Respect for choice
People were offered choices and staff supported them in the least restrictive way. DoLS applications and renewals were handled appropriately.
“People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible.” from the report
Environmental safety
seriousInspectors found an unsafe upper-floor window, unsecured wardrobes, bedrails and glass in unsafe places, and hazardous products in unlocked areas. These problems created risks of falls, injury or harm from substances.
“Environmental risks had not always been identified or promptly addressed.” from the report
Smoking area
seriousThe ashtray was smouldering and overfilled, curtains created a fire risk and there were no formal safety checks. A person who needed supervision was not supervised during the inspection.
“Smoking risks were not always safely managed.” from the report
Medicine records
needs fixingMedicinal patches were recorded inconsistently and some staff signatures were missing from medicine records. This created a risk that medicines might not be given as prescribed.
“This meant there was a risk people would not receive their medicines as prescribed.” from the report
Management checks
seriousAudits did not cover several important safety issues. Medicine and feedback systems also failed to identify problems, and meetings were not recorded.
“Systems and processes in place to monitor the quality and safety of the service were not always effective.” from the report
Care reviews and training
needs fixingPeople said they had not been involved in formal care reviews. Refresher training was not always delivered in line with the provider's policy, and staff had not accessed Mental Capacity Act training.
“Everyone we spoke with told us they had not been involved in formal reviews of their care.” from the report
Navigation and cleaning
minorThe home was difficult to navigate, with limited signage and few distinguishing features for people living with dementia. Some areas were not clean or could not be cleaned effectively because of damaged surfaces.
“There was limited signage to assist people living with dementia to find their way round the service.” from the report
- 01Have all upper-floor windows now been fitted with tamper-proof restrictors, and have the wardrobes been fixed securely to the walls?
- 02What checks now take place in the smoking area, and how is supervision provided for people whose risk assessments require it?
- 03How are medicine patches, staff signatures and as-required medicine protocols checked for completeness?
- 04How are people and relatives involved in formal care reviews, and where are their feedback and meeting records kept?
- 05What action has been completed in response to the fire service's Deficiency Notice?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and the report says ratings for uninspected questions were carried over from the previous inspection. This explanation was written from the published report of 23 September 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 Nursing and Residential Home
4 rated inspections over 7 years: the service has held its Good rating throughout.
- April 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at The Willows Nursing and Residential Home →
- September 2022Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
Read what inspectors found at The Willows Nursing and Residential Home →
- February 2022Inspected but not ratedSafe: Inspected but not rated
- May 2019Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- September 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 14 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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