CQC report explained · a nursing home
What the CQC found at Willow Court
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Unexplained injuries, including bruising and scratches, were not routinely investigated. Risk assessments were usually detailed, medicines were managed safely and infection control arrangements were satisfactory.
- Effective?
- Requires improvement
- Some staff had not completed all required training and some had not received regular supervision. Care assessments and health appointment records did not always provide a complete picture of people's needs.
- Caring?
- Requires improvement
- People looked well cared for and relatives described kind and compassionate care. However, staff interactions were inconsistent, including an example of staff speaking disrespectfully in front of a person.
- Responsive?
- Requires improvement
- Care plans were detailed, but reviews were overdue or not fully recorded and people's goals were not consistently identified. Planned activities had been limited for a long period, although the home had started arranging more.
- Well-led?
- Requires improvement
- Quality checks had identified problems but had not ensured they were fixed. Inconsistent records and weak governance systems meant people were at risk of receiving poor quality care.
What inspectors found, December 2021
Rated Requires Improvement; inspectors found kind care and safe medicines, but gaps in safeguarding, records, staffing and activities.
This was an unannounced inspection on 28 September 2021. Inspectors spoke with people, relatives and staff, observed care, and checked care plans, medicines, staff records and management records. They also checked infection prevention and control.
The home was clean, comfortable and well equipped. People received their medicines safely, had their communication needs supported and could make choices about their care. People and relatives generally said they felt safe and received kind care.
However, unexplained bruises and scratches were not always investigated. Care reviews, health appointment records, staff training and activities were not consistent. The home also had high staff turnover and used agency staff who did not always understand people's needs.
The overall rating and all five question ratings were Requires Improvement. This was a decline from Good in every area at the previous inspection, published on 28 August 2019. The provider was required to send an action plan and CQC said it would monitor progress and return to inspect again.
Safe medicines
People received the correct medicines at the right time. Medicines records, storage and audits were generally safe, although the refrigerator temperature needed immediate attention.
“Medicines were administered in a safe and caring way. People received the correct medicines at the right time.” from the report
Communication support
The home used different tools and technology to help people communicate and understand information.
“People's communication needs were met. The service had an innovative approach to using technology and ensured people had access to information in appropriate formats.” from the report
Comfortable environment
The home was clean, well maintained and adapted to people's sensory and physical needs. People had personalised rooms and access to outdoor space.
“People's care and support was provided in a well-equipped, well-furnished and well-maintained environment.” from the report
Choice and involvement
Staff usually supported people to make decisions and involved families in care decisions where appropriate.
“People were enabled to make choices for themselves and controlled their care and support where possible.” from the report
Unexplained injuries
seriousRecorded bruises and scratches were not routinely treated as incidents or investigated. This meant the home could not establish possible causes or show that people were protected from avoidable harm.
“People were not kept safe from avoidable harm because unexplained injuries such as bruising and scratches were not routinely followed up and investigated to establish potential causes.” from the report
Weak quality checks
seriousManagement audits had identified overdue care reviews, missing activity records and poor health appointment records, but these problems had not been resolved. Records were also inconsistent and not always up to date.
“The lack of robust quality assurance meant people were at risk of receiving poor quality care.” from the report
Staffing and training
needs fixingThe home had experienced high staff turnover and used agency workers. Inspectors saw an agency worker who did not have the necessary skills, while some staff had incomplete training or lacked regular supervision.
“During the inspection we observed an agency support worker did not have the necessary skills.” from the report
Limited activities
needs fixingActivities had not been planned for 18 months, and some people had little interaction or stimulation during the inspection. The home had started arranging more activities.
“People's care files had notes which stated, 'Activity planner out of action due to COVID', which meant activities had not been planned for 18 months.” from the report
Inconsistent respect
needs fixingInspectors saw caring and skilled interactions in some parts of the home, but also saw staff speak about a person's difficulties in front of them. Care and engagement varied between areas.
“The quality of care that people experienced was not consistent because staff interactions varied.” from the report
- 01How are unexplained bruises, scratches or other injuries now recorded, investigated and reviewed?
- 02How often are care plans and care reviews updated, and how will you record the person's goals and aspirations?
- 03How do you check that agency staff understand each person's communication, health and support needs before working with them?
- 04What training and supervision have staff completed, especially training for supporting people with learning disabilities and autistic people?
- 05What regular activities and community opportunities are now available, and how are they matched to each person's interests?
This was an unannounced inspection covering all five CQC questions and infection prevention and control, with observations, discussions and checks of care, medicines, staff and management records. This explanation was written from the published report of 14 December 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.
What inspectors found, August 2019
Willow Court was rated Good; inspectors found kind, safe and personalised care, but one serious-incident notification was delayed.
Inspectors visited the home unannounced on 5 and 6 June 2019. They spoke with people, relatives and staff, and reviewed care records, medicine records, staff files, complaints and management records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough trained staff, safe medicines management, detailed personal care, strong support for independence and a positive culture.
The inspection followed concerns about a serious injury linked to moving and handling equipment. Inspectors did not examine that specific incident because it was subject to further investigation. They found no evidence during this inspection that people were at risk from the wider concern, and said action had been taken to reduce future risks.
Personalised care
Care records were detailed and reflected people's routines, abilities and support needs. People were involved in reviewing their care.
“People received very good, personalised care and support that was specific to their needs and preferences.” from the report
Kind and respectful staff
People and relatives gave positive feedback about staff. Inspectors saw warm, respectful interactions and a calm atmosphere.
“People told us staff were friendly, kind and caring and looked after them well.” from the report
Communication support
The home used pictures, simple language, sign language and assistive technology to help people communicate their choices and needs.
“The service was innovative in the use of assistive technology and other communication aids to meet people's information and communication needs.” from the report
Quality monitoring
The provider had audits, regular reports and action plans to monitor safety and improve the service.
“An effective programme of quality assurance and audits was in place.” from the report
Delayed injury notification
needs fixingOne notification to CQC about a person sustaining an injury was delayed while the registered manager was away. Inspectors discussed reviewing the reporting system to prevent this happening again.
“However, one notification, regarding one person sustaining an injury was delayed due to the registered manager taking annual leave.” from the report
Size of the home
minorThe home was larger than current best practice guidance. Inspectors said the service had worked to reduce any negative impact by focusing strongly on choice, control, independence and inclusion.
“This is larger than current best practice guidance.” from the report
- 01What changes have you made to ensure notifications about serious injuries are sent to CQC without delay?
- 02What safeguards are now in place for falls and injuries involving moving and handling equipment?
- 03How do you make sure the size of the home does not reduce people's choice, independence or opportunities to take part in activities?
- 04How will you support my relative's specific communication method, including any assistive technology they use?
- 05How often will my relative's detailed care plan and risk assessments be reviewed with us?
This was an unannounced planned inspection covering all five key questions; the specific serious injury that prompted some of the concerns was not examined because it was subject to further investigation. This explanation was written from the published report of 28 August 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 Willow Court
3 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- December 2021Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2015
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 11 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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