CQC report explained · a nursing home
What the CQC found at Willow Brook House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risks had been identified and plans were in place, but staff did not always know or follow the required measures. PRN medicine protocols also did not always explain clearly when medicines should be given.
- Effective?
- Requires improvement
- Staffing, training, health appointments, nutrition monitoring and consent arrangements had improved. However, a clinical handover document was still being developed, so changes in people's health might not be easily identified.
- Caring?
- Good
- People were treated with kindness, dignity and respect. They were involved in care decisions and could choose how to spend their time.
- Responsive?
- Requires improvement
- Activities and complaint handling had improved, and people were supported to maintain relationships. Care plans were still basic, and staff needed better guidance to support people with enhanced needs.
- Well-led?
- Requires improvement
- Additional managers and monitoring systems had been introduced, and people and staff felt listened to. The systems were not yet fully embedded, and the inspection could not fully assess their effect because there had been no new admissions and only 17 of 43 places were occupied.
What inspectors found, February 2024
Willow Brook House is rated Requires Improvement; inspectors found kind care and better staffing, but important safety, care planning and management systems still need work.
The inspection was unannounced and took place on 9 and 10 January 2024. One inspector, a specialist nurse adviser and an Expert by Experience spoke with people, relatives and staff. They also checked care records, medicines records, recruitment files and management records.
The home had improved since its previous Inadequate rating. Staffing, medicines, safeguarding, complaints and consent arrangements had improved. People said staff were kind, respectful and responsive, and the caring rating rose to Good.
However, the overall rating remains Requires Improvement. Staff did not always follow risk plans, some medicines instructions were incomplete, care plans were basic, and a new nursing handover system was not yet in place. The systems used to monitor quality and safety also needed to be embedded and sustained.
Kind and respectful care
People and relatives described staff as kind and respectful. Inspectors saw staff using calm, positive language and protecting people's privacy.
“People received kind and compassionate care from staff who used positive, respectful language which people understood and responded well to.” from the report
Improved staffing
The home had recruited permanent staff and was no longer relying on agency staff. Inspectors found enough staff during the visit, including one-to-one support where needed.
“The provider ensured there were sufficient numbers of suitable staff. We saw there was sufficient staff to meet the needs of the people during the inspection.” from the report
Safer medicines arrangements
Medicines were received, stored, administered and disposed of safely. Staff had medicine training and their competence was checked.
“Safe protocols for the receipt, storage, administration and disposal of medicines were followed.” from the report
More activities and improved complaints handling
People had access to exercise, karaoke, walks and other activities. Complaints were recorded, investigated and shared with staff.
“Since the last inspection the registered manager had ensured people had more access to a variety of activities.” from the report
Risk plans were not always followed
seriousStaff did not always understand or apply the measures in people's risk plans. Inspectors gave an example of prescribed anti-embolic socks not being worn.
“Risks to people's care had been identified but the measures in place to mitigate those risks were not always consistently applied.” from the report
Incomplete medicine instructions
needs fixingSome PRN medicine protocols did not explain clearly how a person might appear when they needed the medicine. This could make it harder for staff to know when to give it.
“PRN protocols provide staff with sufficient information to guide them as to when to administer the prescribed medicine.” from the report
Health handover not yet in place
needs fixingA clinical handover document was being developed but had not been implemented. The inspectors could not yet assess whether it would help nursing staff notice deterioration quickly.
“At the time of the inspection this had not yet been implemented.” from the report
Basic care plans and limited activity guidance
needs fixingCare plans did not give a detailed enough picture of people's preferences and needs. Staff also needed more guidance about suitable activities for a person receiving enhanced support.
“Care plans were basic and included people's preferences, likes and dislikes, spiritual and communication needs.” from the report
Quality checks needed strengthening
needs fixingManagement checks and records did not always show whether actions had been completed. Some checks focused on the building and did not include people's clinical needs.
“The systems in place to monitor the quality and safety of the service needed to be improved, embedded and sustained to be able to fully assessed.” from the report
End-of-life plans were limited
minorSome advance care plans contained only basic information about people's wishes, spiritual needs and resuscitation decisions. No one was receiving end-of-life care during the inspection.
“The information was limited and included people's basic wishes as to where they may wish to be at the end of life, their spiritual needs and cardiopulmonary resuscitation (DNACPR) decisions.” from the report
- 01How do you check that staff understand and follow each person's risk plan, including instructions such as wearing anti-embolic socks?
- 02What has been changed in the PRN medicine protocols, and how do staff decide when a person needs an as-required medicine?
- 03Has the clinical nursing handover document now been introduced, and how do you identify a change or deterioration in someone's health?
- 04How are care plans being made more detailed and person-centred, particularly for people needing enhanced one-to-one support?
- 05What evidence shows that management checks are completed and that actions from meetings and audits are followed through?
This was an unannounced follow-up inspection covering all five key questions after the previous Inadequate rating; the impact of recent management changes could not be fully assessed because there had been no new admissions and only 17 of 43 places were occupied. This explanation was written from the published report of 17 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, August 2023
Rated Inadequate and placed in special measures; inspectors found serious risks in staffing, medicines, care planning, nutrition and management.
This was an unannounced inspection on 9 and 11 May 2023. Inspectors spoke with people, relatives, staff and health professionals. They reviewed care records, medicine records, staff files, incidents, audits and management documents.
The home was not consistently safe. There were not enough suitably skilled staff, heavy reliance on agency workers, missing risk assessments, medicine shortages and delays, and unsafe arrangements around food, fluids and choking risks. People had also been admitted without checking whether their needs and compatibility with others could be managed.
Inspectors found that consent, care planning, communication, complaints and healthcare arrangements were not handled properly. People were not always involved in their care, and the home did not have effective systems to monitor quality and put known improvements into practice.
The overall rating was Inadequate. Safe, Effective, Responsive and Well-led were rated Inadequate, while Caring Requires Improvement. The home was placed in special measures, meaning CQC will monitor it and usually re-inspect within six months.
Safe recruitment checks
The home followed recruitment checks for permanent and agency staff, including references and DBS checks.
“They received references of previous employment and carried out Disclosure and Barring Service (DBS) checks” from the report
Infection prevention
Inspectors were assured that infection prevention arrangements, personal protective equipment and visiting arrangements were being managed appropriately.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Kind and helpful staff
Some people, particularly in one unit, described staff as kind, caring, attentive and willing to listen.
“I think the staff do a great job, they come and talk to you, they have time to listen” from the report
Encouraging independence
People said they could make choices about dressing, getting up, bathing and showering when they were able to do so.
“I can get out of bed and into my chair, I only need help with bathing.” from the report
Family contact
Relatives were allowed to visit freely, and people were supported to stay in contact with important people.
“Relatives were able to visit freely.” from the report
Staffing and supervision
seriousThere were not enough permanent and suitably skilled staff for people's complex needs. The home relied heavily on agency staff who might not know people well.
“There were not enough staff with the skills, competencies and experience to meet people's clinical and care needs.” from the report
Medicines were missed or late
seriousFifteen people missed 167 doses because medicines were out of stock. Morning medicine rounds took over four hours, and time-critical medicines were not always given on time.
“Between 9 April and 6 May 2023 15 people had missed 167 doses of their prescribed medicine” from the report
Incomplete risk and care planning
seriousImportant risks, including falls, moving and handling, skin damage and choking, were not always assessed or recorded. Staff therefore did not always have the information needed to provide safe care.
“People did not have all their risks assessed or have care plans which provided staff with the information they needed to mitigate known risks.” from the report
Food, drink and choking risks
seriousSome people did not receive the correct texture of food or drink. Fluid monitoring and nutrition screening were also incomplete, putting people at risk of choking, dehydration or malnutrition.
“One person's food and fluid charts showed staff regularly gave them the wrong texture of food” from the report
Consent and least restrictive care
seriousThe home had not completed required capacity assessments or best-interest meetings for people receiving continuous one-to-one observation and other care decisions.
“There were no records of a best interest meeting to discuss the impact of continuous observations” from the report
Complaints and involvement
needs fixingPeople and relatives said verbal complaints were not consistently logged, answered or resolved. People were also not routinely involved in care planning or invited to residents' or relatives' meetings.
“People's verbal complaints had not been responded to.” from the report
- 01How many permanent nurses and care staff are now in post, and how are agency staff's skills and knowledge checked?
- 02How do you ensure all prescribed medicines, especially time-critical medicines, are available and given on time?
- 03Have every resident's risk assessments and care plans been completed and reviewed with them and their relatives?
- 04What has changed to ensure people receive the correct food and drink texture and enough fluids?
- 05How are capacity assessments, best-interest decisions, complaints and healthcare appointments now recorded and followed up?
This was an unannounced inspection covering all five key questions, including infection prevention and control; it was the first inspection since the home registered on 21 July 2022. This explanation was written from the published report of 11 August 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.
Every inspection of Willow Brook House
2 rated inspections over a year: the service has improved, from Inadequate to Requires improvement.
- February 2024Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2023InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- July 2022
Registered with the Care Quality Commission on 21 July 2022.
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
How to read CQC ratings and reports
What to check when you visit
89 live-in carers within about an hour of North Northamptonshire
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 £1,260 a week. 76 can care for a couple. 12 years' experience on average.
“If you bump into her in the night on her way to the bathroom she will still inquire how you are and if everything is alright.”
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.