CQC report explained · a nursing home
What the CQC found at Willow Lodge Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed and managed, safeguarding procedures were followed, medicines were stored and given safely, and recruitment checks were completed. People and relatives said there were enough staff and calls for help received a quick response.
- Effective?
- Good
- People had their needs assessed and reassessed, and staff were trained and supervised. People were supported to eat and drink, access healthcare, and receive care in line with mental capacity requirements.
- Caring?
- Good
- People and relatives described staff as kind and caring. Inspectors found that privacy, dignity, personal choices, cultural needs and spiritual needs were respected.
- Responsive?
- Good
- Care plans reflected people's preferences and changing needs. Activities, communication aids, family involvement and compassionate end-of-life care were available.
- Well-led?
- Good
- People, relatives and staff spoke positively about the management. The home used audits, meetings, feedback and complaints to monitor and improve care, and refurbishment work was under way.
What inspectors found, March 2020
Rated Good; inspectors found safe, kind and personalised care, with improvements still under way to activities, dining and communication support.
This was an unannounced inspection on 30 January and 3 February 2020. Inspectors spoke with five people, three relatives, four staff and healthcare professionals. They reviewed care records, staff files and management records.
The inspectors rated the home Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. They found that people were protected from abuse, received their medicines safely, and had staff who were trained and suitable. People were supported with food, healthcare, personal care and decisions about their lives.
People and relatives said staff were kind and knew people well. Care was personalised, relatives were involved, and activities and end-of-life support were available. The home was renovating and refurbishing parts of the building, and had plans to improve activities outside the home and the dining experience.
The Good rating means the inspectors found the home was meeting the relevant standards and providing consistently good care at the time of this inspection. The previous inspection rating was also Good, published on 11 November 2017.
Safe medicines and risk management
The home used risk assessments, safety equipment and medicines checks to reduce avoidable harm. Staff also learned from mistakes, including medicines recording errors.
“People's medicines were stored, administered and recorded appropriately.” from the report
Consistent, caring staff
The staff team was stable and knew people well. Relatives said this helped staff understand people who could no longer communicate verbally.
“People were supported by a consistent staff team who had supported them for many years, enabling positive relationships to grow over time.” from the report
Personalised care
Care plans recorded individual preferences, including clothing, drinks and how staff should approach people with sight problems. People and relatives were involved in care planning.
“People received personalised care. People and their relatives participated in continually evolving care plans.” from the report
Good healthcare support
The home worked with hospitals, local authorities and healthcare professionals. People received visits from services including dental, optician, physiotherapy and a weekly GP round.
“People were supported to accesses healthcare professionals whenever they required.” from the report
End-of-life care
People and relatives were involved in advance care planning. The home involved appropriate healthcare professionals and had medicines available to help manage pain or anxiety.
“People identified to be approaching end of life were treated with dignity and compassion by staff.” from the report
Activities outside the home
minorThe report says the home had plans to improve how often people took part in activities outside the home. Ask what progress has been made.
“Management plans were also in place to improve the frequency of activities for people outside of the service” from the report
Dining experience
minorThe dining experience was identified for improvement. The home was also planning to introduce a pictorial menu to help people make meal choices.
“Management plans were also in place to improve the frequency of activities for people outside of the service and their dining experience at the care home.” from the report
Communication support still developing
minorThe home was developing some ways to support communication, including a pictorial menu and easier-to-read policies. Ask how these changes were completed and used.
“The service was developing the means by which it supported people's communication needs.” from the report
- 01What progress has been made with the planned improvements to the dining experience?
- 02How often can residents now take part in activities outside the home?
- 03Has the pictorial menu been introduced, and how do you support people with dementia or failing vision to make choices?
- 04What refurbishment work has been completed since the inspection, and how do you minimise disruption to residents?
- 05How do you make sure staffing levels continue to match residents' changing needs?
This was an unannounced comprehensive inspection covering all five CQC areas, and all five ratings were Good. This explanation was written from the published report of 14 March 2020 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 2017
Willow Lodge Nursing Home was rated Good; inspectors found safe, kind and personalised care, with no breaches reported.
This was an unannounced, comprehensive inspection. Inspectors visited the home, spoke with people, relatives, staff and health and social care professionals, observed care, and checked care plans, medicines records, staff files and quality checks.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines, suitable training, personalised care plans, kind care and good systems for handling complaints and checking quality.
The home had changed provider and was re-registered in November 2016. This was therefore its first inspection and rating under the new provider. There was no registered manager in post at the time, although a permanent manager had applied and was waiting for the CQC's decision.
Kind and respectful care
People and relatives spoke positively about the care. Inspectors saw staff build warm relationships and protect people's privacy and dignity.
“We saw staff looked after people in a way which was kind and caring.” from the report
Safe staffing and medicines
Inspectors found enough staff to respond to people, and medicines records showed people received their medicines as prescribed.
“There were robust systems in place to ensure medicines were managed safely.” from the report
Personalised support
Care plans recorded people's routines, preferences, interests and support needs. Staff knew people well and used this information in their care.
“Each person had an up to date and personalised care plan, which set out how their care and support needs should be met by staff.” from the report
Activities and choice
People were encouraged to join activities that matched their interests, while those preferring time alone were offered social contact in their bedrooms.
“People had opportunities to participate in meaningful social activities.” from the report
Quality monitoring
The provider used regular audits, visits, meetings and surveys to gather views and monitor the quality of care.
“The new home manager and provider had introduced effective governance systems to monitor and review the quality of care they delivered.” from the report
No registered manager in post
needs fixingThe previous registered manager had left in January 2017. A permanent home manager had applied to become registered but was still waiting for the outcome at the inspection.
“The service is required to have a registered manager, but has not had one in post since January 2017.” from the report
Bedroom labels
minorInspectors found labels on bedroom furniture identifying clothing and bedding. The manager agreed they could appear undignified, and they were removed during the inspection.
“We discussed this issue with the home manager who agreed these labels looked unsightly and might be perceived as patronising and/or undignified for people using the service.” from the report
- 01Has the permanent home manager since become the registered manager, and who is responsible for the home if the application is still pending?
- 02How many staff are on duty for each shift, and how do you increase staffing when someone needs one-to-one support or attends a healthcare appointment?
- 03How often are care plans and risk assessments reviewed now, and how are families involved when people's needs change?
- 04What activities are currently available for people who enjoy group activities and for those who prefer individual time?
- 05How are complaints recorded, investigated and shared with families?
This was an unannounced comprehensive inspection covering all five key questions and providing the service's first rating under the new provider. This explanation was written from the published report of 11 July 2017 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 Nursing Home
2 rated inspections over 3 years: the service has held its Good rating throughout.
- March 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2016
Registered with the Care Quality Commission on 2 November 2016.
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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