CQC report explained · a nursing home
What the CQC found at The Willows Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2022
Rated Good after a focused inspection found safer medicines management and better oversight than at the previous inspection.
Inspectors visited without notice on 11 October 2022. One inspector reviewed medicines, care records, risk assessments, recruitment files and quality checks. They also observed care and spoke with staff.
The home was rated Good for Safe and Well-led. Inspectors found medicines were stored, recorded and given safely. Risks were assessed, the environment was clean, and systems were in place to manage incidents, complaints, safeguarding concerns and infection control.
The previous rating was Requires Improvement, published in December 2021. The provider had been in breach of regulations about safe care and treatment and good governance. Inspectors found enough improvement had been made and the provider was no longer in breach.
Safe medicines
Medicines were safely stored, recorded and administered. Staff received training and had their knowledge and competence checked.
“People received their medicines safely and as prescribed.” from the report
Risk and infection control
Risks to people's health, mobility and activities were assessed and regularly reviewed. The home was clean and had systems for preventing and controlling infection.
“There were regular audits of infection control and cleanliness and suitable systems for managing waste and laundry.” from the report
Quality monitoring
The provider used audits, checks and technology to monitor the service. Inspectors found that appropriate action was taken when problems were identified.
“There were systems for monitoring and improving the quality of the service and these were operated effectively.” from the report
Person-centred care
Staff provided care that inspectors described as kind and personalised. People could make choices about their care, and the home supported cultural, religious and language needs.
“Staff provided personalised care, which was kind, sensitive and caring.” from the report
Temporary staffing
minorThe home relied on some agency staff to cover vacancies, although it aimed to use familiar temporary staff and was recruiting permanent staff.
“The provider relied on some temporary (agency) staff to help cover staffing vacancies.” from the report
New manager registration
minorThe previous manager had recently left. A new manager was in post but was still applying to register with CQC when inspectors visited.
“They had started the process of applying to be registered with CQC.” from the report
- 01How many permanent staff vacancies remain, and how often are agency staff now being used?
- 02Has the new manager completed their application to register with CQC?
- 03How often are medicines audits completed, and what happens when an error or concern is found?
- 04What improvements from the previous action plan are being checked now?
- 05What were the ratings for Effective, Caring and Responsive at the previous comprehensive inspection?
This was a focused inspection of Safe and Well-led only; the other question ratings were carried over from the previous inspection. This explanation was written from the published report of 28 October 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.
What inspectors found, December 2021
Rated Requires Improvement; inspectors found improvements in infection control and medicines management, but medicines errors and weak checks still posed a risk.
This was an unannounced focused inspection on 27 October 2021. One inspector and a member of the medicines team spoke with people, relatives and staff, observed care, and checked care plans, medicines records, recruitment files and management records.
The home had improved its infection control arrangements, risk assessments, staffing checks and some medicines processes. Relatives said people were safe and well cared for. However, one person received the wrong medicine dose for four days, and staff could not show that some medicines safety checks were working properly.
The overall rating remains Requires Improvement. Safe and Well-led were both rated Requires Improvement. The other three questions were not inspected during this visit, so their previous ratings were used in the overall rating.
Improved infection control
Inspectors found the home was clean and had processes for cleaning, COVID-19 risks and protective equipment. The home was no longer in breach of this part of the safe care and treatment regulation.
“The provider had infection control processes in place to manage possible risk.” from the report
Risk assessments
The home had detailed guidance for risks including diabetes, seizures, choking, falls, poor nutrition and skin damage. Emergency evacuation plans were also in place.
“Guidance was provided for care workers and nurses on how to reduce possible risks.” from the report
Recruitment checks
The recruitment records checked included employment histories, references and criminal record checks. Inspectors found the provider's recruitment process was robust.
“The provider had a robust recruitment process in place which enabled them to check new staff had the appropriate skills and knowledge for their role.” from the report
Positive feedback
The person and relatives spoken with said they were happy with the care and felt people were safe. Staff said they felt supported by managers.
“Relatives confirmed they were happy with the care their family member received” from the report
Incorrect medicine dose
seriousOne person received an incorrect dose of a medicine for four days. Staff acted when inspectors raised it, and the person's GP was contacted, but this still put people at risk and was a continued breach.
“We noticed that a person had received an incorrect dose of a medicine for four days.” from the report
Medicines checks were not reliable
seriousThe home had not shown that it acted on relevant medicines safety alerts. Staff also could not demonstrate that blood glucose testing kits were calibrated correctly, and some medicine care plans lacked enough detail.
“The provider had not implemented a system for demonstrating they had received or taken action relating to relevant medicines safety alerts.” from the report
Weak quality audits
seriousThe medicines audit did not identify the administration error before the inspection. Inspectors said the quality assurance system was not robust enough to make sure medicines were given as prescribed.
“The provider had not ensured their quality assurance process in relation to medicines was robust enough to ensure medicines were administered as prescribed.” from the report
- 01What changes have been made to prevent another incorrect medicine dose?
- 02How do you now check that medicines safety alerts have been received and acted on?
- 03How do you make sure blood glucose testing kits are correctly calibrated?
- 04How often are medicines audits completed, and who checks that they identify and fix errors?
This was a focused inspection of Safe and Well-led, mainly checking earlier Warning Notices; the other key question ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 21 December 2021 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 Home
7 rated inspections over 8 years: the service has held its Good rating throughout.
- October 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- August 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- May 2019Requires improvementstayed Requires improvementSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- May 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- August 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 20 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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At least 100 live-in carers within about an hour of Ealing
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 £1,300 a week. 77 can care for a couple. 11 years' experience on average.
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