CQC report explained · a residential care home
What the CQC found at Willow Court
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found safe medicines management, enough skilled staff, suitable infection control and improved risk assessments, but recommended fire drills that reflect night-time staffing.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- The provider had improved oversight, staff training and quality checks. There was no registered manager at the time, but an interim manager was overseeing the home and a permanent manager had started afterwards.
What inspectors found, October 2022
Willow Court rated Good; inspectors found safe, well-managed care, with a recommendation about night-time fire drills.
This was an unannounced focused inspection on 8 and 16 September 2022. One inspector spoke with people living at the home, relatives and staff, and checked care, medicine, recruitment, fire safety and management records.
The home was rated Good for Safe and Well-led. Inspectors found enough skilled staff, safe medicines management, suitable infection control and improved risk assessments. People were supported to make choices and staff understood their needs.
The inspection followed concerns about fire safety, but inspectors found no evidence that people were at risk of harm from this concern. They recommended that fire drills include night-time conditions and the smaller night staff team.
The previous overall rating was Requires improvement, with breaches of regulations. The provider had made improvements and was no longer in breach. This inspection only assessed Safe and Well-led, so the other ratings carried over from the previous inspection.
Safe staffing
Inspectors found enough skilled staff to meet people's needs. Extra one-to-one support was provided where needed.
“There were enough skilled staff to meet the needs of people using the service.” from the report
Medicines
Medicines were administered, stored and recorded safely. Records were complete and medicines were audited.
“Medicines were stored safely, and administration records were completed fully. Medicines were well organised and audited.” from the report
Choice and independence
People were supported to make choices and have control over their lives. Staff used the least restrictive approach and supported people in their best interests.
“People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests” from the report
Improved management
The provider had strengthened monitoring, staff training and fire safety checks since the previous inspection. Inspectors found the provider was no longer in breach of the earlier governance regulation.
“There were systems in place to monitor the quality and safety of the service.” from the report
Night-time fire drills
needs fixingDay and night staff had attended fire drills together. Inspectors recommended a drill using night-time staffing levels, so night staff could practise their expected role without extra day staff support.
“We recommend the provider consider current guidance regarding fire drills to simulate night time conditions which would include the applicable night staffing levels.” from the report
Evacuation plans
minorPeople's personal emergency evacuation plans did not initially record their mobility needs clearly. Management added this information during the inspection.
“Whilst staff were clear about people living at the service mobility needs, it was not reflected in the PEEP.” from the report
Communication with relatives
minorMost relatives were happy, but one relative said communication could be better, particularly about positive events at the home.
“one relative thought communication could be better particularly in respect of positive things happening at the service.” from the report
- 01Have you completed a fire drill using the night-time staffing levels, and what did you learn from it?
- 02Are personal emergency evacuation plans checked regularly and kept up to date with each person's mobility needs?
- 03Who is now managing the home permanently, and how is the change in management being overseen?
- 04How will you keep relatives informed about positive events and changes in people's care?
- 05What quality checks are now used to make sure the improvements from the previous inspection are maintained?
This was a focused inspection of Safe and Well-led following fire safety concerns; Effective, Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 21 October 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.
What inspectors found, July 2021
Rated Requires Improvement; inspectors found risks in dignity, risk assessments, infection control and management oversight, although medicines and safeguarding were generally handled safely.
This was an unannounced focused inspection in February 2021. Inspectors looked mainly at Safe and Well-led because of safeguarding concerns. They spoke with people, relatives and staff, observed care, and checked care, medicines, staffing and management records.
The home was not always safe. Some risk assessments did not give staff enough guidance, infection control rules were not always followed, and instructions for some covert medicines were not detailed enough. Inspectors found that people received their medicines safely and as prescribed, and staff understood safeguarding procedures.
The home was not always well-led. Inspectors saw that people were not always treated with dignity or spoken to in a respectful way. Some people were not communicated with in their preferred way. The systems used to check care quality had not identified these problems.
The overall rating fell from Good at the previous inspection, published in October 2018, to Requires Improvement. The report says there was no evidence that people had been harmed during this inspection, but some systems placed people at risk of harm.
Medicines
The home had systems for giving and storing medicines safely. Staff had medicines training and competency checks.
“Systems were in place to ensure people received their medicines safely and as prescribed.” from the report
Safeguarding
Staff understood how to recognise and report possible abuse. The manager had recorded and reported safeguarding concerns when necessary.
“Staff received training about safeguarding people from abuse and whistleblowing and demonstrated a clear understanding of their responsibilities.” from the report
Staffing and recruitment
Required recruitment checks were completed before staff started work. The home had enough staff to meet people's needs, including extra staff during a COVID-19 outbreak.
“Enough staff were employed at the service to meet people's needs.” from the report
Family communication
Relatives said they were involved in care and kept informed about changes, including information about COVID-19.
“Relatives told us they were involved with the delivery of care to their family members and were kept informed of any changes.” from the report
Risk assessments
seriousCare plans and risk assessments did not always contain current, clear guidance for staff. One person with epilepsy did not have enough guidance about how to provide safe support.
“One person with epilepsy did not have an adequate risk assessment to give sufficient guidance to staff on how to support the person.” from the report
Infection control
needs fixingSome staff wore masks incorrectly and staff were regularly seen not following social distancing rules. Inspectors said improvements were needed to follow government guidance effectively.
“Staff were regularly observed not practising social distancing rules with each other as per government guidelines to help reduce the spread of infection.” from the report
Dignity and communication
seriousPeople were not always spoken to respectfully, and staff did not always use people's preferred communication methods. Inspectors found a breach of the dignity and respect regulation.
“Staff did not always speak to people in a way that promoted dignity and respect.” from the report
Management oversight
seriousThe home's checks did not identify problems with dignity, risk assessments, communication and care practice. Inspectors found a breach of the good governance regulation.
“This meant people were possibly placed at risk of harm.” from the report
- 01What has changed so staff consistently use each person's given name and speak to them with dignity and respect?
- 02How do you now record and review risks, including risks linked to epilepsy, and make sure staff follow the guidance?
- 03How do you check that staff use people's preferred communication methods, including sign language where required?
- 04What action has been taken to improve mask wearing, social distancing and other infection control practices?
- 05How do your quality checks now identify problems before they place people at risk, and what did CQC's required action plan change?
This was an unannounced focused inspection of Safe and Well-led, prompted partly by safeguarding concerns; the other key questions were not inspected and previous ratings were carried forward. This explanation was written from the published report of 3 July 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 Willow Court
4 rated inspections over 6 years: the service has held its Good rating throughout.
- October 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- December 2018Goodstayed GoodSafe: GoodWell-led: Good
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- May 2011
Registered with the Care Quality Commission on 12 May 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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