CQC report explained · a nursing home
What the CQC found at Willett Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, September 2022
Rated Requires Improvement; inspectors found progress, but ongoing risks with choking, medicines, dignity and management systems.
This was an unannounced, comprehensive inspection on 28 June 2022. Inspectors spoke with people, relatives, staff and health professionals. They observed care and checked care plans, medicines records, staff files and management records.
Some improvements had been made since the previous inspection. Wound care, falls management, moving and handling, staff recruitment and infection control had improved. People and relatives generally said they felt safe, and staff were described as kind and familiar with people's needs.
However, the home did not always manage choking risks or medicines safely. Care records were sometimes conflicting, incomplete or out of date. Inspectors also found that people's dignity was not always respected, activities were not always provided, and mental capacity and best-interest decisions were not always recorded.
All five areas were rated Requires Improvement: Safe, Effective, Caring, Responsive and Well-led. This means the home was not consistently meeting people's needs and there was limited assurance about safety.
Improvement in some safety areas
Inspectors found that wound care, falls management and moving and repositioning had improved. Staff had clearer guidance and used equipment safely.
“Improvements made were embedded and sustained in practice, had improved managerial oversight and helped ensure people's health following a fall was monitored appropriately.” from the report
Kind relationships
People and relatives spoke positively about staff. Inspectors saw warm interactions, and staff knew people well.
“We observed interactions between people and staff which were warm and genuine.” from the report
Staff training and healthcare links
Staff had training and supervision, and people could access health professionals. Feedback from professionals was positive about the improvements.
“Staff had undertaken suitable training for their role and had the knowledge and skills to meet people's needs.” from the report
Safeguarding and complaints
Safeguarding concerns were reported and investigated, with action taken to reduce repeat risks. Complaints were investigated and used to make some improvements.
“Incidents were analysed, and actions taken to reduce the risk of reoccurrence.” from the report
Choking risks
seriousSome records gave conflicting information about choking risks. One person at high risk was eating alone in bed without safe positioning or staff following the care plan.
“This placed the person at risk of potential harm.” from the report
Medicines management
seriousTwo people received time-sensitive medicines late, in one case by up to an hour. Records did not show that checks on some higher-risk medicines had always been completed.
“People who were prescribed time sensitive medicines specific to their health condition had not always received medicines as prescribed.” from the report
Dignity and privacy
needs fixingA person was weighed using a hoist in a communal area. Staff also discussed personal continence and health information where others could hear.
“People's dignity was not always respected.” from the report
Incomplete personalised care records
needs fixingCare plans did not always record people's preferences, personal histories, communication needs or current goals in enough detail. Some records were out of date or lacked guidance for staff.
“People's care plans were not always holistic and did not always contain information which reflected their current needs, preferences and aspirations.” from the report
Mental capacity records
seriousCapacity assessments and best-interest decisions were not always recorded when restrictive practices, such as bedrails, were used. This meant the provider could not assure inspectors that people's rights were protected.
“Records did not provide evidence of people's involvement in the decision-making process.” from the report
Activities and environment
needs fixingSome people were not supported with suitable alternative activities when they did not join group entertainment. Parts of the building were not fully adapted for people with dementia or other difficulties navigating.
“Not all people were supported to take part in activities relevant to them.” from the report
- 01What changes have been made to ensure every person at risk of choking has a clear, current care plan, and how are staff checked against it?
- 02How will you ensure time-sensitive medicines are given on time and that checks on higher-risk medicines are recorded?
- 03How do you protect people's dignity during weighing, personal care and conversations about health or continence?
- 04How are mental capacity assessments and best-interest decisions recorded when bedrails or other restrictive practices are used?
- 05How do you make sure activities are delivered and that people who do not enjoy group entertainment are offered suitable alternatives?
This was an unannounced comprehensive inspection covering all five key questions and checking compliance with conditions imposed after the previous inspection. This explanation was written from the published report of 8 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. The report was longer than we could read in one go; the later sections may not be reflected.
What inspectors found, August 2021
Rated Requires Improvement; inspectors found risks were not managed reliably, recruitment checks were not robust enough, and the home was not always person-centred.
This was an unannounced focused inspection on 13 April 2021. Inspectors looked mainly at whether people were safe and whether the home was well-led. They spoke with people, relatives and staff, observed care, and checked care records, medicines records, recruitment files and management records.
The inspectors found that care plans and risk assessments were often not updated when people's needs changed or incidents happened. Guidance from health professionals was not always recorded or followed. An agency worker had started without a proper induction or access to important care information. These problems increased the risk of avoidable harm.
The overall rating changed from Good to Requires Improvement. Safe and well-led were both rated Requires Improvement. The other three areas were not inspected at this visit, so their previous ratings were used. The home had some strengths, including kind staff, safe medicines practice and infection control measures.
Kind and compassionate staff
Inspectors found staff to be kind and compassionate. Relatives also said their family members were safe and well cared for.
“People were cared for by staff who were kind and compassionate.” from the report
Medicines
Medicines were stored, administered and monitored safely. Staff had completed medicines training and had been assessed as competent.
“Medicines were managed safely. Staff had completed medicines training and had been assessed as competent before giving people medicines.” from the report
Infection control
Staff had infection prevention training and the home's infection control practice was generally in line with government guidance. Inspectors found safe systems for PPE, testing, hygiene and managing outbreaks.
“Staff had received training in infection prevention and control (IPC) and IPC practice within the home was aligned with current government guidance.” from the report
Safeguarding awareness
There were systems for reporting possible abuse. Staff knew how to report concerns, and the manager had made required safeguarding referrals and notifications.
“Staff understood their responsibilities for reporting concerns.” from the report
Risk plans were not kept up to date
seriousCare plans and risk assessments did not always contain enough detail or reflect changes after incidents. This included falls, injuries, pressure wounds and a person leaving the home without staff knowledge.
“People's risks were not always assessed, monitored or managed in a way that consistently kept them safe.” from the report
Agency staff checks and induction
seriousAn agency worker started without an induction or access to electronic care records. The provider could not be sure the worker was safe or had the right skills and training.
“The agency staff member working their first shift, had not received an induction or access to people's electronic care records.” from the report
Limited meaningful activity
needs fixingInspectors saw a task-focused culture and too little regular activity to support people's social and emotional wellbeing. The planned activities programme was not happening consistently.
“We observed a lack of meaningful activity throughout the day to ensure social and emotional needs were considered.” from the report
Infection control gaps
needs fixingVisiting professionals were not always asked for a COVID-19 lateral flow test. Furniture was not always arranged for social distancing, and COVID-19 policies were not fully up to date.
“When visiting professionals attended the service, they were not always asked to complete a lateral flow device test (LFD) for Covid-19 or provide evidence that one had been completed.” from the report
Governance did not identify problems
seriousQuality checks did not reliably identify patterns in falls or shortfalls in wound care, recruitment and clinical records. This meant the provider did not have effective oversight of safety and quality.
“Quality processes and systems in place did not always identify risks relating to the health, safety and welfare of people.” from the report
- 01How are risk assessments and care plans updated after a fall, injury, pressure wound or other change in a resident's needs?
- 02What checks are completed before agency staff start work, and how are they given information about residents' risks and care needs?
- 03What has changed since the inspection to make sure advice from specialist health professionals is recorded and followed?
- 04How often are meaningful activities now provided, and how are residents' social and emotional needs assessed?
- 05What conditions has CQC placed on the registration, and what evidence can you show that these conditions are being met?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 17 August 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 Willett Lodge
5 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- September 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- May 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2017Goodstayed GoodSafe: Good
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 12 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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28 live-in carers within about an hour of West Sussex
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 £1,020 to £1,170 a week. 23 can care for a couple. 11 years' experience on average.
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