CQC report explained · a residential care home
What the CQC found at Willoughby House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, February 2024
Rated Good overall, but inspectors found leadership and quality checks needed improvement.
This was an unannounced, focused inspection on 8 January 2024. Inspectors visited the home, spoke with people, relatives, staff and professionals, and checked care, medicines, recruitment and quality records. The inspection activity ended on 19 January 2024.
The home was rated Good for Safe. Inspectors found enough suitably skilled staff, safe recruitment, good safeguarding knowledge and safe support with medicines. They also found kind care, respect for privacy and dignity, support with choices, and good links with health professionals.
The home was rated Requires Improvement for Well-led. Quality checks were not always effective, two alleged abuse notifications were not sent to CQC promptly, and some records needed updating. A new manager had started improvements, but some changes still needed to be fully put into practice.
The overall rating is Good, but this inspection did not check Caring, Effective or Responsive. Those ratings were carried forward from the previous inspection in 2019. The inspection was prompted partly by concerns about how people were treated, but inspectors found no evidence to support those concerns.
People felt safe
People and relatives told inspectors they felt safe. Staff knew how to recognise and report abuse, and understood people's risks.
“Staff had received training in abuse awareness and had a good knowledge of how to identify and report concerns.” from the report
Kind and respectful care
Inspectors found that staff provided compassionate care, respected privacy and dignity, and understood people's individual needs.
“People received kind and compassionate care. Staff protected and respected people's privacy and dignity.” from the report
Choice and independence
People were supported to make choices about daily life, activities, food and their rooms. Staff helped people take part in interests and activities in the local community.
“Staff supported people to take part in activities and pursue their interests in their local area with people who had shared interests.” from the report
Consistent staff team
Low staff turnover meant people were supported by staff who knew them well. Inspectors found staff understood people's communication needs and care plans.
“Staff turnover was very low, which supported people to receive consistent care from staff who knew them well.” from the report
Clean and welcoming home
The home was clean and tidy, with safe infection control practices. Visitors were able to visit without restrictions.
“The service was very clean and tidy but still captured a 'homely' feel.” from the report
Delayed reporting of alleged abuse
needs fixingTwo notifications about alleged abuse were not reported to CQC promptly. The provider later submitted them and introduced new systems, but this shows an important weakness in oversight.
“This had resulted in 2 notifications of alleged abuse not being reported to CQC in a timely manner.” from the report
Management oversight was incomplete
needs fixingSome management posts were vacant and quality monitoring was limited to manager-level audits. Records and guidance for staff were not always up to date.
“The provider did not have a fully supported management structure as these posts were currently vacant.” from the report
Some records and authorisations needed attention
needs fixingThe manager was reviewing care plans, risk assessments and medicines records. Some DoLS authorisations had expired while the home waited for reassessment.
“Some DoLS authorisations had expired and they were awaiting reassessment by the local authority.” from the report
- 01How do you now make sure alleged abuse and other notifiable events are reported to CQC promptly?
- 02Which management posts are still vacant, and who is responsible for checking the quality of care?
- 03Have all care plans, risk assessments, medicines records and staff guidance now been reviewed and updated?
- 04What is the current position on the expired DoLS authorisations, and how are people's rights protected while reassessment is awaited?
- 05How will you show that the new manager's improvement plan has been fully put into daily practice?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the 2019 inspection. This explanation was written from the published report of 2 February 2024 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, June 2019
Rated Good in all five areas; inspectors found safe, kind, personalised care and a well-run home.
This was an unannounced, planned inspection on 28 May 2019. One inspector spoke with five people, staff, the manager and a relative. They looked at care records, medicines, staffing, safety documents and the building.
The inspectors found that people were safe and received effective care. Staff managed medicines and risks well, supported healthcare needs, and helped people make choices and build independence. People were treated with kindness, dignity and respect.
Care was personalised and communication needs were met. People were supported to take part in activities, keep relationships and use the local community. The home had good leadership, regular checks and systems for responding to complaints. All five areas were rated Good, as at the previous inspection published in November 2016.
Choice and independence
People were supported to make choices, take responsible risks and develop skills. They were encouraged to use local services and live as independently as possible.
“People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.” from the report
Kind and respectful care
People had trusting relationships with staff. Inspectors saw that staff respected people's preferences, dignity and privacy.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Personalised communication
The home adapted communication to people's needs. Staff used signs, written information, pictures and communication passports.
“Strategies were used to enable people to receive information in a format they understood.” from the report
Good leadership
The manager and staff promoted a friendly, positive culture. Regular audits, meetings and action plans were used to monitor and improve the service.
“Records showed when action was completed.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you assess and support my relative's communication needs, including at healthcare appointments?
- 02How will you involve my relative and our family in creating and reviewing their person-centred support plan?
- 03How do you support people to take part in activities, keep relationships and use the local community?
- 04How will you review medicines, including any medicines that may be suitable for reduction?
- 05What recent quality checks or action plans have led to improvements in the home?
This was an unannounced planned inspection of the overall service, including care, premises, records, medicines, staffing and all five CQC questions. This explanation was written from the published report of 28 June 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 Willoughby House
3 rated inspections over 7 years: the service has held its Good rating throughout.
- February 2024Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2019Goodstayed GoodSafe: GoodWell-led: Good
- November 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2013
Report published without a new overall rating.
- July 2012
Registered with the Care Quality Commission on 10 July 2012.
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.
Weigh the report against the rest
Fees, photos and reviews from families
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What to check when you visit
9 live-in carers within about an hour of Lincolnshire
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.
8 can care for a couple. 10 years' experience on average.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.