CQC report explained · a residential care home
What the CQC found at Willow Lodge Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not always given according to prescriptions or at suitable times. Inspectors also found that the home had run out of epilepsy medicine, while other safety systems, staffing and infection control arrangements were satisfactory.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used to calculate the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used to calculate the overall rating.
- Responsive?
- Good
- Care plans reflected people's preferences and communication needs. People were supported with activities, relationships, complaints and compassionate end of life care.
- Well-led?
- Requires improvement
- Medicine audits and management oversight had not identified or dealt with the medicines concerns. Inspectors also found a positive culture, clear roles and confidence in the registered manager.
What inspectors found, June 2023
Willow Lodge Care Home is rated Requires Improvement; inspectors found serious medicines problems alongside kind, personalised care.
This was an unannounced focused inspection on 25 May 2023. Inspectors spoke with people, relatives and staff, observed care, and checked care plans, medicines records, staff files and management records.
The main concern was medicines safety. Some medicines were not given as prescribed or at the right time. The home ran out of one person's epilepsy medicine, and that person was admitted to hospital after having a seizure following three days without the medicine.
Inspectors found enough staff, detailed care plans, good safeguarding arrangements and kind, person-centred care. People were supported with activities, communication, relationships and end of life care.
The safe and well-led ratings were Requires Improvement. Responsive was rated Good. Effective and Caring were not inspected during this focused visit, so their previous ratings were used in calculating the overall rating. The overall rating fell from Good to Requires Improvement.
Enough staff
Inspectors found enough staff to meet people's needs, with call bells answered in a timely way. Staff knew people well and recruitment checks were completed.
“There were enough staff to meet people's needs and our observations confirmed this.” from the report
Personalised care
Care plans gave detailed guidance about people's preferences and the support they needed. Staff encouraged people to make choices about their daily lives.
“People received a person-centred service.” from the report
Safeguarding
Staff knew how to recognise and report abuse. Inspectors found that safeguarding systems were operating effectively.
“Systems and processes to protect people from the risk of abuse were operating effectively.” from the report
Activities and relationships
People were supported to see family and friends and take part in interests and activities, including trips into the local community.
“People were supported to maintain relationships and take part in activities.” from the report
End of life care
End of life plans recorded people's wishes and preferences. The home worked with health professionals and provided compassionate support.
“People who were nearing the end of their life, received compassionate and supportive care.” from the report
Medicines missed or late
seriousMedicines were not always given as prescribed or at the right time. One person went without epilepsy medicine for three consecutive days, had a seizure and was admitted to hospital.
“There was a failure to ensure safe processes for medicines.” from the report
Weak medicines oversight
needs fixingAudits did not identify medicines administration problems, and managers were not aware of the concerns until inspectors raised them. The home had not consistently sought medical advice or identified the causes of missed medicines.
“Medicine audits were not robust enough to identify the concerns we found with people's medicines.” from the report
- 01What changes have you made to ensure medicines are given at the prescribed time?
- 02What happened after the independent review of medicines practices planned for June 2023?
- 03How do you check that medicine stock is reconciled accurately and that essential medicines do not run out?
- 04How are missed or late medicines recorded, medically reviewed and investigated?
- 05How will you show families that the medicines audit system now identifies problems quickly?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were used to calculate the overall rating. This explanation was written from the published report of 24 June 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.
What inspectors found, February 2021
Willow Lodge Care Home was rated Good overall, but Safe Requires Improvement despite major improvements in care planning, infection control and management.
Inspectors made an unannounced focused visit on 13 January 2021. They spoke with people, relatives, staff and health and social care professionals. They observed care and checked care, medicines, staffing and management records.
The home had improved since its previous inspection. Care plans and risk assessments were updated, infection control had improved, medicines were managed safely, and staff felt more confident. People and relatives spoke positively about the care and the atmosphere was described as happy.
Safe was still rated Requires Improvement because electronic records did not always accurately show care that had been delivered, and there were staffing pressures at some busy times. Effective and Well-led were rated Good. The overall rating changed from Requires Improvement to Good, using some ratings carried forward from the previous comprehensive inspection.
Improved risk management
Risk assessments gave staff clear instructions about how to reduce risks. The provider had acted on concerns from the previous inspection.
“There were clear risk assessments in place for people. These included clear guidance for staff on how to mitigate risks in people's care.” from the report
Infection control
Inspectors were assured that PPE, testing, hygiene and visiting arrangements were being managed safely. Communal areas had also been changed to support distancing.
“We were assured the provider was using PPE effectively and safely.” from the report
Kind and person-centred care
People spoke positively about staff. Inspectors saw staff spending time with people and supporting their individual needs and preferences.
“We observed people and staff enjoying each other's company. Staff took time to stop and chat with people.” from the report
Effective health support
Staff worked proactively with health and social care professionals. The report gives an example where person-centred support helped avoid a hospital admission.
“Staff worked effectively and pro-actively with healthcare professionals to ensure people received good support.” from the report
Stronger management
New management arrangements, audits and action plans had improved how the home was run. Staff described feeling more like a team.
“There were systems in place to assess and monitor the quality of care people received.” from the report
Electronic care records
needs fixingSome electronic records did not accurately show the care delivered. Repositioning tasks sometimes appeared as missed, although other notes showed the care had been provided.
“We noted some gaps or discrepancies in the way information was recorded.” from the report
Busy morning staffing
needs fixingSome people and staff said there was pressure on staffing in the morning. Call bell responses were generally quick, but took longer between 8am and 9am.
“Daytime you get everybody wanting at the same time, there aren't enough of them to go round” from the report
Areas where distancing was difficult
minorSocial distancing was not always possible in corridors and some office spaces. Inspectors discussed ways to reduce the risk, including better ventilation.
“There were occasions where it was not possible to socially distance, for example in the corridors and in some office spaces.” from the report
- 01How do you now check that electronic care records accurately show care that has been delivered, including repositioning care?
- 02How many staff and senior staff are present in communal areas during the busiest morning period?
- 03What are the usual call bell response times between 8am and 9am?
- 04How are remaining actions in the improvement plan monitored and signed off?
- 05What arrangements are now in place for ventilation in corridors and office spaces where distancing is difficult?
This was an unannounced focused inspection of Safe, Effective and Well-led, with some ratings from the previous comprehensive inspection carried forward; Caring and Responsive were not separately assessed. This explanation was written from the published report of 12 February 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 Lodge Care Home
5 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- June 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2021Goodup from Requires improvementSafe: Requires improvementWell-led: Good
- January 2021Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- August 2020Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- January 2019Goodstayed GoodSafe: GoodEffective: Requires improvementResponsive: GoodWell-led: Good
- April 2016GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- October 2012
Registered with the Care Quality Commission on 11 October 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.
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