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.
What inspectors found, February 2019
Rated Good overall, but well-led was Requires Improvement because some notifications were not sent to CQC and there was no registered manager.
Inspectors visited on 8 and 9 January 2019 without telling the home in advance. They spoke with people living there, a relative, staff and a visiting professional. They observed care and meals and checked care, staff, medicines and quality records.
They found people were safe and received kind, personalised care. Medicines, risks, infection control, food and drink, health support and end-of-life care were managed well. Staff training for nurses had improved since the previous inspection, and the earlier breach about nursing staff training no longer applied.
The home was rated Good overall and Good for Safe, Effective, Caring and Responsive. Well-led was rated Requires Improvement because some notifications about Deprivation of Liberty applications were not sent to CQC. There was also no registered manager in post.
Safe care
Inspectors found that staff understood safeguarding and that risks, accidents and medicines were managed carefully.
“People had been protected from the risk of harm and abuse by a staff team who were knowledgeable about identifying and responding to concerns.” from the report
Improved nursing training
The home had acted on the previous inspection finding. Nursing staff were receiving training and regular competency checks.
“We reviewed the nursing competency assessments and found these had been completed regularly.” from the report
Kind and respectful staff
Staff took time to reassure people and supported their privacy, dignity and choices.
“We observed staff throughout the inspection and saw they were polite and took their time to respond to people and reassure them.” from the report
Personalised care
Care plans recorded people's needs, preferences, backgrounds and communication methods. They were updated when people's needs changed.
“People received person centred care which reflected their needs and preferences.” from the report
Good oversight of care
The home used audits, meetings and action plans to monitor care and address issues that were found.
“An effective governance framework was in place which ensured the deputy manager had a clear oversight of the service.” from the report
No registered manager
needs fixingThere was no registered manager in post. The deputy manager was managing the home temporarily with support from the registered manager of the separate sister home.
“At the time of this inspection there was no registered manager in post at The Willows.” from the report
Missing CQC notifications
needs fixingThe provider had not told CQC about applications for Deprivation of Liberty authorisations or their outcomes. The report says CQC was considering its response separately.
“The provider had not notified CQC of applications for Deprivation of Liberty authorisations or the outcomes of these applications, as required by the regulations.” from the report
Training records spread across systems
minorInspectors found it difficult to tell when some staff training needed renewing. They asked the home to provide one up-to-date training matrix.
“The home would benefit from having a clear record of all training done and the date including the date of renewal in one place.” from the report
Staff were very busy
needs fixingStaff said they could provide care safely but would prefer more staff. Inspectors also saw that busy periods left staff with less time to listen to people.
“Staff appeared to be very busy and reported they felt more staff would be better but felt able to provide care and support safely.” from the report
Mixed views about activities
minorPeople had different views about whether there was enough stimulation. Inspectors could not see an activities noticeboard during the visit, although the home said it was being updated.
“People gave us mixed views on whether they had enough stimulation.” from the report
- 01When do you expect a registered manager to be appointed, and who is responsible for the home until then?
- 02How do you now make sure all required Deprivation of Liberty notifications and outcomes are sent to CQC?
- 03How many staff are normally on duty for the current number and needs of residents, and how do you respond when staff are very busy?
- 04Can you show me the current training matrix, including renewal dates for staff training?
- 05What activities are currently available, and how are residents told about them?
This was an unannounced inspection covering all five key questions, with particular attention to pressure care and improvements promised after the January 2018 inspection. This explanation was written from the published report of 6 February 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.
What inspectors found, April 2018
Rated Requires Improvement; inspectors found safe, kind and responsive care, but nurse training and management oversight were not sufficient.
This was a comprehensive inspection of both parts of the home. The first day was unannounced. Inspectors visited on 31 January and 1 February 2018. They spoke with people, relatives, staff and a visiting health professional. They reviewed 16 care files, medicines records, staff records and other documents, and observed care, meals and the premises.
The home was rated Good for Safe, Caring and Responsive. People were generally treated with kindness and dignity. Medicines were managed safely. Care plans were personalised, risks were recorded and complaints were dealt with appropriately. Inspectors also found enough staff during the visit and improvements in pressure care since the previous inspection.
The home was rated Requires Improvement for Effective and Well-led. Nurses working through an agency or on a self-employed basis had not received training from the provider. The registered manager had not received clinical supervision. Some consent records were incomplete, and there were areas to improve around activities and communication at weekends.
The overall rating of Requires Improvement means the home was not consistently meeting the expected standard in all areas. The provider was in breach of Regulation 18 about staffing, training, supervision and competency. The provider was asked to send an action plan, and CQC said it would check that the action was taken.
Safe medicines
Inspectors found medicines were stored, given and recorded safely. They found no gaps in the medicines administration records they checked.
“We found that medicines were managed safely.” from the report
Kind and respectful care
Staff knew people well and treated them with dignity. People were offered choices and staff respected privacy during personal care.
“We saw staff had built relationships and had a good rapport with people.” from the report
Personalised care plans
Care plans included people's needs, preferences, backgrounds and risks. Daily records showed care was provided in line with people's requests.
“Care files were person centred and contained information that was personal to each person's circumstances and history.” from the report
Pressure care improved
The home was no longer in breach of the previous pressure-care regulation. People were repositioned when required and relevant care plans were in place.
“As a result we were able to determine the service was no longer in breach of this regulation.” from the report
Activities could be better
minorInspectors did not observe activities on the dementia unit. Some people and staff said there could be more activities, and one activities coordinator position was vacant.
“People and their relatives told us they participated in activities such as parties, colouring and craft making; however some felt there could be more done with people.” from the report
Weekend contact
minorOne person said it could be difficult to contact the managers at weekends when the administrator's office was closed. The home said it had addressed this with staff, but CQC planned to monitor it.
“One person did comment that during the weekend it was hard to contact the managers due to having no contact number or email address for them when they were not present in the building.” from the report
- 01What training and competency checks have all agency and self-employed nurses completed since this inspection?
- 02How often does the registered manager now receive clinical supervision, and who provides it?
- 03Have all consent forms been checked and signed, including evidence for any lasting power of attorney covering health and welfare?
- 04What activities are now available on both units, and who is responsible for organising them?
- 05What contact number or process is available for families who need to speak to management at weekends?
This was a comprehensive inspection of both units, covering all five key questions, with particular attention to pressure care following a serious injury notification. This explanation was written from the published report of 5 April 2018 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
5 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- February 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2018Requires improvementdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2017Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2015Requires improvementstayed Requires improvementSafe: InadequateEffective: Requires improvement
- February 2015Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2014
Report published without a new overall rating.
- June 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 25 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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