CQC report explained · a nursing home
What the CQC found at Willow Rose Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors only looked at staffing pressures and infection prevention and control. They were assured that the home had suitable arrangements for admissions, PPE, testing, visiting and managing infection outbreaks.
- Effective?
- Good
- This question was not assessed in this targeted inspection.
- Caring?
- Good
- This question was not assessed in this targeted inspection.
- Responsive?
- Good
- This question was not assessed in this targeted inspection.
- Well-led?
- Good
- This question was not assessed in this targeted inspection.
What inspectors found, February 2022
Inspected but not rated; inspectors found good infection control arrangements for the designated COVID-19 setting.
This was an announced, targeted inspection on 28 January 2022. Inspectors gave the home 12 hours' notice. They checked infection prevention and control arrangements for an area intended for up to four people discharged from hospital with COVID-19.
No people were living in this area during the inspection. Inspectors found that people could self-isolate, use separate entrances and have their own en-suite facilities. Staff working there would not work elsewhere in the home during the same shift.
The home was rated inspected but not rated overall, and the Safe question was also inspected but not rated. This was not a full inspection of the home, so the report does not provide a new overall rating.
Separate infection control arrangements
The designated area allowed people to self-isolate. People who tested positive and the staff working with them could use separate entrances.
“People admitted to the unit, identified for the designated setting, would be able to self-isolate in line with current guidance.” from the report
Dedicated staff team
Staff assigned to the designated area would work only there during their shift, reducing movement between areas.
“People would be supported by a cohort of staff who would work solely on the self-contained unit during their shift.” from the report
PPE and staff training
The report says staff would use PPE in line with guidance and had infection prevention and control training.
“People would be supported by staff wearing Personal Protective Equipment (PPE) in line with current guidance and fully trained in infection prevention and control.” from the report
Contact with relatives
The home had arrangements for window visits, telephone calls and video calls, with processes for other visits if needed.
“People would be supported to communicate with their relatives through window visits, telephone and video calls and there were processes in place to accommodate visits should the need arise.” from the report
Inspectors raised no specific concerns in this report.
- 01How have the arrangements for the designated area worked in practice since the inspection?
- 02How do you check that staff use PPE correctly and keep their infection prevention and control training up to date?
- 03How do you manage staff pressures linked to COVID-19, and how do you make sure the dedicated staff group remains separate?
- 04How are visits arranged now, including visits for relatives of people who test positive?
- 05How are infection prevention and control audits carried out, and what action is taken when a shortfall is found?
This was a targeted inspection of infection prevention and control and related staffing arrangements in the designated setting only; the whole service and the other key questions were not assessed. This explanation was written from the published report of 18 February 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, November 2021
Rated Good; inspectors found kind, safe and personalised care, with some records and infection control practice needing improvement.
This was the home’s first inspection since it registered. It was unannounced and took place on 20, 21 and 25 October 2021. Inspectors spoke with people, relatives and staff, and checked care, medicine and management records.
The home was providing personal and nursing care for 51 people aged 65 and over, with capacity for 73. All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led.
People and relatives said they felt safe and well supported. Inspectors found kind staff, personalised care, safe medicines, suitable support with food and drink, activities, healthcare access and dignified end of life care.
There were some shortfalls. Staff were sometimes seen wearing masks below their noses. Some people's religious, cultural or communication needs were not clearly recorded, and one staff risk assessment and incident reviews needed clearer documentation.
Kind and personal care
Inspectors observed positive interactions. People and relatives described staff as compassionate and personal in their approach.
“All the inspection team observed positive interactions between staff and people across both days of inspection.” from the report
Choice and independence
People could make everyday choices about food, clothing and activities. Staff encouraged people to stay independent.
“People were encouraged to make day to day decisions, for example, what they ate, what they wore and what they did.” from the report
Food and drink
Mealtimes were arranged around people's needs, with choices about meals and where to eat. Inspectors found the dining environment calm and food well presented.
“Mealtimes were arranged to suit people's individual needs.” from the report
Activities and relationships
The home offered varied activities and helped people maintain contact with relatives and the local community.
“People were offered a range of activities and we were told a 'wake up and shake up' session took place every morning in the communal lounges.” from the report
Safe medicines
Medicines were managed safely, including controlled medicines. Staff received training and competency checks.
“Medicines were managed safely to ensure people received them in accordance with their health needs and the prescriber's instructions.” from the report
Masks were not always worn correctly
needs fixingInspectors saw some staff wearing masks below their noses. The manager said this would be raised with staff and checked through observations.
“We observed some occasions where staff were wearing masks below their nose.” from the report
Some personal needs were not recorded clearly
needs fixingOne person's religious and cultural needs were not fully explored or documented. Another person's first language needs lacked clear guidance for staff.
“However, one person's religious and cultural needs had not been fully explored with them.” from the report
Incident reviews needed more detail
minorThe home reviewed accidents and incidents, but records did not always clearly show how patterns and trends had been identified or what factors had been considered.
“However, it wasn't always clear how patterns and trends had been identified and what factors had been considered.” from the report
One staff risk assessment was incomplete
minorOne staff member had a risk assessment, but the record did not show how risks would be reduced. The manager completed this during the inspection.
“However, one staff member had a risk assessment in place, but the risk mitigation had not been recorded.” from the report
- 01What checks do you now carry out to make sure staff wear masks correctly?
- 02How do you record and review each person's religious and cultural preferences, including wishes about end of life care?
- 03How will you support someone who communicates in a language other than English?
- 04What changes have you made to show clearly how accidents and incidents are analysed and lessons are learned?
- 05How do you make sure staff risk assessments include clear steps to reduce identified risks?
This was an unannounced planned inspection of the home covering all five CQC key questions and infection prevention and control; it was the first inspection since registration. This explanation was written from the published report of 17 November 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 Rose Care Home
Each visit the CQC has published, newest first, back to the day the home was registered.
- February 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- November 2021GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2019
Registered with the Care Quality Commission on 28 November 2019.
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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