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, September 2023
Requires Improvement; inspectors found kind care and some safety measures, but governance systems and records were not yet reliable.
This was an unannounced focused inspection. Inspectors visited on 27 June, 29 June and 6 July 2023, reviewed records remotely until 17 July, spoke with people, relatives, staff and health professionals, and checked care, medicines, staffing and management records.
The home was rated Requires Improvement for Safe and Well-led. Risks were recorded on a new electronic system, people received medicines on time, staff understood safeguarding, and action had been taken after an incident involving sore skin. However, some risk assessments, medicines records and care records lacked important detail, and staffing at busy times had caused delays.
The provider was still breaching Regulation 17 on good governance. New monitoring systems and audits had been introduced, but inspectors said these needed to be embedded and strengthened. The overall rating remained Requires Improvement, as did the previous rating, and this was the home's third consecutive Requires Improvement rating.
Kind and respectful staff
People and relatives described staff as kind, loving and approachable. Inspectors also observed positive interactions between people and managers.
“The staff are lovely so kind and caring they work very hard to make sure everyone is looked after.” from the report
Medicines given on time
Inspectors found that people received their medicines when they needed them. Staff also encouraged people who were reluctant to take them.
“People received their medicines when they needed them.” from the report
Safeguarding understanding
Staff had safeguarding training and understood how to report concerns. People said they felt safe in the home.
“Staff we spoke with had a good understanding of what to do to make sure people were protected from harm or abuse.” from the report
Learning from incidents
The home investigated incidents, reviewed patterns and took action to reduce the risk of them happening again. This included new equipment and alerts for missed care tasks.
“Systems were in place to record and learn from incidents or accidents.” from the report
Working with other professionals
The registered manager worked with health professionals and the local authority. A health professional said concerns were escalated quickly.
“The staff work well with us and implement any recommendations we share.” from the report
Governance breach continued
seriousThe provider had not yet made enough improvement to ensure records, audits and monitoring systems reliably tracked the quality and safety of care. This was a continued breach of Regulation 17.
“Not enough improvement had been made at this inspection and the provider was still in breach of regulation 17.” from the report
Care records needed more detail
needs fixingSome risk assessments did not contain enough person-centred information, and the new electronic care planning system was not yet fully embedded. Inspectors said further work was needed to keep records accurate.
“This needed to be further embedded to ensure accurate person-centred records were maintained.” from the report
Busy-time staffing pressures
needs fixingSome people had to wait for meals because of staff deployment and shift changes at peak times. Staffing was increased on each floor during the inspection.
“We saw at peak times there were some occasions where people had to wait for meals due to the deployment of staff and staff change overs.” from the report
Medicines recording errors
minorInspectors found several recording problems, including undated creams, incomplete instructions and a missing body map. These issues were addressed during the inspection.
“We found some recording discrepancies such as handwritten instructions not being countersigned, some creams not dated upon opening” from the report
Wear and tear
minorSome furniture and equipment showed wear and tear and needed attention. The home had action plans in place.
“We observed some wear and tear of furniture and equipment which required addressing.” from the report
- 01What has changed since the inspection to make sure care records and risk assessments contain complete, person-centred information?
- 02How are staffing levels and staff deployment being monitored at busy times, and are people still waiting for meals or care?
- 03What is the current progress on the Regulation 17 action plan, and how will you show that improvements are sustained?
- 04How are medicines records, including cream instructions, opening dates, body maps and supplement stock, checked now?
- 05How are daily care records and monitoring charts audited to identify missed or overdue care?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from the previous inspection and used to calculate the overall rating. This explanation was written from the published report of 2 September 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, April 2019
Rated Requires Improvement; inspectors found kind staff and medicines were given as prescribed, but risks, dignity and care records needed improvement.
This was an unannounced inspection on 20 February 2019. Inspectors spoke with people, relatives, visitors, staff and managers. They sampled care, medicine, recruitment, training and management records.
People said they felt safe and staff were often described as kind. However, risk assessments and care records were not always up to date. Staff deployment, training checks, medicine storage, food choices and support with people's preferences also needed improvement.
The home was rated Requires Improvement in all five areas: Safe, Effective, Caring, Responsive and Well-led. This was the same overall rating as the previous inspection, published on 19 December 2017. The provider had started an improvement plan, but CQC said it would continue to monitor the home.
People felt safe
People told inspectors they felt safe. Staff knew people's individual risks and emergency plans were in place for a fire.
“People we spoke with felt safe, one person said, "I couldn't feel safer. I like it here and staff look after me.” from the report
Medicines given as prescribed
Medicine records showed that people received their medicines on time and as prescribed. Staff understood how to give medicines for specific needs such as Parkinson's disease and diabetes.
“Medicine records confirmed people received their medicines on time and as prescribed.” from the report
Safe recruitment
The provider completed pre-employment checks, including references and criminal records checks, before staff started work.
“Pre-employment checks were completed before staff started to work at the service, this included reference and Disclosure and Barring Service (DBS) criminal records checks.” from the report
Clean environment
Inspectors found the home clean and without unpleasant odours. Staff used gloves and aprons when providing personal care.
“The service was clean and odour free.” from the report
Access to healthcare
Staff monitored people's health and referred them to healthcare professionals when needed. Advice from a speech and language therapy team was recorded and followed.
“People's health was monitored by staff and when required people were referred to relevant health care professionals.” from the report
Open management
The management team was described as approachable. The manager acknowledged the challenges and had started an action plan.
“The registered manager was open and honest about the challenges they faced within the service and how they were going to manage these.” from the report
Incomplete risk information
seriousSome care plans and risk assessments were out of date or missing important detail. This could lead to inconsistent care and increased risk to people's health and safety.
“This put people at risk of receiving inconsistent care.” from the report
Medicine storage and records
needs fixingMedicine trolleys were not secured adequately. Records about returned or refused medicines could not be found during the inspection.
“Improvements were required in the safe storage and disposal of medicines.” from the report
People left waiting
needs fixingAlthough there were enough staff overall, staff deployment needed improvement. Inspectors saw people waiting for care while staff completed paperwork.
“We observed some people had to wait for their care needs to be met whilst staff completed paperwork.” from the report
Dignity and privacy
needs fixingStaff did not always provide personal care promptly. Bedroom doors were often left open, meaning people could sometimes be seen partially clothed or in night clothes.
“We observed people's bedroom doors were often left open and we and other visitors could observe people partially clothed or sitting in their night attire.” from the report
Limited choice and engagement
needs fixingFood menus were repetitive and choices were limited. Staff did not always ask about people's preferences or engage with them when they had the opportunity.
“People told us they did not always get their needs met in the way they preferred or in a way that was responsive to their needs.” from the report
Weak quality checks
seriousAudits did not identify inaccurate and incomplete care records or training monitoring problems. CQC found this was a breach of Regulation 17.
“The failure to have effective governance systems and processes in place to monitor and mitigate risks to people was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
- 01How have you ensured that risk assessments and care plans are now accurate and detailed, especially for dementia and end of life care?
- 02What has changed in staff deployment so people do not wait for care while staff complete paperwork?
- 03How are you now checking staff training results, competencies and supervision?
- 04How are medicine trolleys secured, and how are returned or refused medicines recorded?
- 05What do you do to protect people's privacy, dignity, food choices and personal preferences when staff are busy?
This was an unannounced planned inspection that looked at the premises and care provided and assessed all five CQC questions; the overall rating remained Requires Improvement from the previous inspection. This explanation was written from the published report of 2 April 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 Nursing Home
5 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- September 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- December 2017Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2017Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- March 2011
Registered with the Care Quality Commission on 22 March 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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