CQC report explained · a nursing home
What the CQC found at Willow Tree Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, August 2022
Willow Tree Lodge was rated Good; inspectors found safe, kind care and clear improvements, with a few fire safety and infection-control actions still in progress.
This was an unannounced focused inspection on 21 and 25 July 2022. One inspector spoke with people, relatives, staff and visiting health professionals. They also observed care and checked care, medicine, recruitment and management records.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, safe medicine systems, suitable risk assessments and appropriate safeguarding processes. People said they felt safe and received help when they needed it.
The home had improved since the last inspection, when it was rated Requires Improvement. Checks and action plans were more effective, and the manager worked with staff and other professionals to improve care. Some fire door work and infection-control guidance updates were still being dealt with.
This was not a full inspection of all five areas. The overall Good rating used the new Safe and Well-led ratings together with ratings from the previous comprehensive inspection for the other areas.
People felt safe
People said they felt safe and staff responded when help was needed. Risk assessments and care plans guided staff in supporting people safely.
“People told us they felt safe living at the service and knew who to speak to if they had any concerns.” from the report
Improved management
The home had improved since the previous inspection. Audits were more comprehensive, and identified problems were put into action plans.
“They had put this learning in to practice and auditing was more comprehensive.” from the report
Kind staff
People described staff as kind and helpful. The manager worked alongside staff and had regular oversight of their practice.
“People were supported by staff who treated them with kindness and showed them compassion.” from the report
Learning from incidents
Incidents were recorded, investigated and reviewed for patterns. The home changed its admission process after one medicine-related incident.
“Lessons from incidents were learnt and action was taken to reduce re-occurrence.” from the report
Fire door work
needs fixingThe fire service had identified areas needing improvement, including replacing some fire doors. This work was under way during the inspection.
“The fire service had identified some areas that needed improvement, for example replacing some fire doors.” from the report
Activities staffing
minorThere was no activities co-ordinator at the time of the inspection. The provider was recruiting, while existing staff continued to support activities.
“There was no activities co-ordinator at the time of the inspection, but the provider was in the process of recruiting one.” from the report
- 01Have the fire doors identified by the fire service now been replaced, and are any related actions still outstanding?
- 02How do you make sure the infection prevention and control policy and guidance stay up to date?
- 03Has an activities co-ordinator been recruited, and what activities are currently available each day?
- 04What were the previous ratings for Effective, Caring and Responsive, which were carried forward into this overall rating?
- 05How can residents and relatives raise concerns or suggest changes, and how will the home show what action was taken?
This was a focused inspection of Safe and Well-led only; the other three key question ratings were carried over from the previous comprehensive inspection when calculating the overall rating. This explanation was written from the published report of 10 August 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, December 2019
Rated Requires Improvement; the home improved from Inadequate and left special measures, but safety and leadership still need work.
Inspectors visited on 24 and 25 October 2019. The first day was unannounced and the second was announced. They spoke with people, relatives and staff, and checked care, medicines, risk and management records.
The home had improved considerably since earlier inspections. Inspectors found enough staff, kind and respectful care, personalised support, activities and good access to health professionals. Medicines were given safely and the environment was cleaner and better maintained.
Safety and leadership were both rated Requires Improvement. Inspectors were not yet fully confident that staffing and management checks would remain effective when more people moved in. Effective, Caring and Responsive were rated Good.
The home had previously been rated Inadequate and was in special measures from 2 May 2019. It was no longer in special measures after this inspection, and inspectors found no current breaches of regulation.
Kind and respectful care
People and relatives were positive about staff. Inspectors saw staff protecting dignity, encouraging independence and responding warmly to people.
“People's dignity was actively respected.” from the report
Improved staffing
There were enough staff for the people living at the home during the inspection. Staff were deployed across the floors and call bells were answered quickly.
“At this inspection we found there were sufficient staff to meet people's needs.” from the report
Personalised support
Care plans recorded people's routines, preferences, communication needs and interests. Staff had more time to talk with people and provide support that matched their wishes.
“Care provided to people was now person centred.” from the report
Safer medicines and environment
People received medicines as prescribed. Equipment, fire safety arrangements and infection control had improved, and repairs had been made to the building.
“People received their medicines when they needed them and as prescribed by their doctors.” from the report
Staffing when more people move in
seriousThe home had 22 people, although it was registered for up to 34. Inspectors could not be wholly confident that staffing would match people's needs at full capacity.
“We could not be wholly confident that assessment of staffing levels will meet needs when, potentially, 12 new people are accommodated at the service.” from the report
Management systems not fully embedded
needs fixingManagement checks had improved, but inspectors wanted to see whether they would continue to identify and fix problems over time.
“We could not be certain that processes to effectively assess, monitor and improve the quality and safety of the service were fully embedded.” from the report
- 01How will you check staffing levels if more people move into the home?
- 02What checks are now carried out on care plans, medicines, incidents, safeguarding and the building?
- 03How will you show that management checks continue to work when the home is operating closer to its capacity of 34 people?
- 04How are people and relatives involved in reviewing care plans, activities and complaints?
- 05What further improvements have been made since the October 2019 inspection?
This was a planned inspection covering all five key questions, following earlier Inadequate ratings and concerns about the service. This explanation was written from the published report of 4 December 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 Tree Lodge
7 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- August 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2019Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
- July 2019Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementWell-led: Inadequate
- July 2019Inadequatedown from Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- April 2018Requires improvementup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2017Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- April 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- November 2011
Registered with the Care Quality Commission on 3 November 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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