CQC report explained · a residential care home
What the CQC found at Willow View
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Risk assessments were complete and regularly reviewed. Staff recruitment, safeguarding, lone working and medicines systems were found to be safe.
- Effective?
- Good
- The home worked within the principles of the Mental Capacity Act. Staff had relevant training and supervision, and healthcare needs were recorded and supported.
- Caring?
- Good
- Staff supported privacy, dignity, choice and independence. Communication methods included pictures, signs, emotion cards and social stories.
- Responsive?
- Requires improvement
- Activities were not always varied or regular enough, and the complaints procedure was only in text format. Care plans were detailed, current and regularly reviewed.
- Well-led?
- Good
- Staff felt supported and management checks were carried out regularly. The home used feedback and action plans to monitor and improve care.
What inspectors found, May 2018
Rated Good overall; inspectors found safe, kind and well-managed care, but activities and accessible complaints information needed improvement.
This was an unannounced inspection on 20 and 28 March 2018. Inspectors reviewed care records, medicines, recruitment, training and management records. They also spoke with staff, a relative and a healthcare professional, and received some non-verbal feedback from the person living at the home.
The overall rating was Good. Safe, Effective, Caring and Well-led were all rated Good. The home had improved since January 2017, when it was rated Requires Improvement and had two breaches of regulations.
Responsive was rated Requires Improvement. Activities were not always varied or regular enough, and the complaints procedure was only available in text. Inspectors found that risk assessments, behaviour plans, medicines management, staff training and care records had improved.
Improved safety planning
Risk assessments and behaviour support plans were detailed, complete and regularly reviewed. The home also learned from incidents and updated its plans.
“There were a range of risk assessments in place that identified environmental risks and risks to the person such as nutrition and development of pressure ulcers.” from the report
Safe medicines
Medicines records had no unexplained gaps. Staff were trained and their competence was checked.
“All staff had received medicines training and were observed administrating medicines by the provider so that their competence could be checked.” from the report
Person-centred communication
Staff used several communication methods to help the person express choices and understand changes or visits.
“The service used 'social story' work to help communicate with the person.” from the report
Good staff support
Staff received regular supervision, training and induction. They said they could ask for further training when needed.
“Staff had supervision with their supervisor monthly, this gave staff the opportunity to talk about any concerns they had, any development areas and training needed.” from the report
Regular quality checks
Management carried out regular checks across areas such as medicines, infection control and health and safety. Shortfalls led to action plans.
“The residential care director completed monthly quality monitoring in a range of areas such as infection prevention and control, medicines and health and safety.” from the report
Activities were limited
needs fixingThe range of activities was not as varied as it could have been. Important activities had stopped for a period, although the home planned to restart and widen them.
“Activity provision did not always provide opportunity to regularly engage in key identified activities.” from the report
Complaints information was not accessible
needs fixingThe complaints procedure was only available in text. Inspectors said the person would struggle to use it and the manager agreed that a pictorial version would help.
“There was a complaints procedure in place however it was only available in one format, which the person would struggle to use.” from the report
- 01Which activities are currently available, and how will you make sure important activities do not stop again?
- 02Has the complaints procedure been provided in a pictorial or other accessible format?
- 03Who is currently responsible for managing the home, and has the application to become a registered manager been completed?
- 04How do you use the person's communication methods, such as signs, pictures and emotion cards, when planning daily care?
- 05How are incidents in the community reviewed, and how are changes to risk assessments explained to staff?
This was an unannounced inspection covering all five CQC questions, the premises and the care provided; the report also checked that improvements required after the January 2017 inspection had been made. This explanation was written from the published report of 16 May 2018 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, April 2017
Rated Requires Improvement; inspectors found kind, skilled support, but gaps in risk assessments, fire-safety actions and care plans.
The inspection took place on 5 January 2017. The inspector gave the registered manager short notice because the person living at the home could not tolerate unfamiliar visitors. The inspector spent limited time at the home, reviewed records and spoke with staff, the deputy and the registered manager.
Staff knew the person well and understood their triggers. They supported the person with daily choices, meals, activities and family relationships. Medicines were managed safely, staff had suitable training, and recruitment checks were in place.
The main problems were incomplete risk assessments, an outstanding fire-safety recommendation and care plans that did not contain enough detail. Behaviour plans were not updated after incidents. The home was rated Requires Improvement overall, with Safe and Responsive also rated Requires Improvement. Effective, Caring and Well-led were rated Good.
Caring relationships
Staff knew the person well, built trust and used approaches that respected their communication and need for personal space.
“People benefitted from a person centred culture and the staff were committed to providing a service which put people at the centre of their care and treatment.” from the report
Staff training
Staff received an induction, mandatory training and specialist training intended to help them respond to changing needs.
“Members of staff were supported to develop their skills and deliver the roles and responsibilities of employment.” from the report
Medicine systems
Medicine profiles gave staff instructions about medicines, their purpose, side effects and the person's preferred way of taking them.
“The safe handling of medicine systems were in place.” from the report
Activities and choices
The person helped plan meals and activities, went shopping for food and took part in activities such as visits to the park and horse-riding.
“The person developed a daily planner and this was on display in the kitchen.” from the report
Incomplete risk assessments
seriousRisk assessments did not cover all relevant risks, including what staff should do when the person came into contact with feared animals. The report says this increased the potential risk to the person and staff.
“Risk assessments were not in place on the actions staff need to take when people come in contacted with animals they fear.” from the report
Fire-safety action outstanding
seriousA fire risk assessment had made recommendations, but not all had been completed when inspectors visited.
“The property was assessed for the potential risk of fire and recommendations were made to maintain a safe environment. However, not all the recommendations were met.” from the report
Out-of-date behaviour guidance
seriousPositive behaviour plans had not been reviewed after the person's admission or after challenging incidents. This meant staff did not have consistently updated guidance.
“Positive behaviour management plans had not been reviewed following the person's admission to the service or following challenging incidents.” from the report
Care plans lacked detail
seriousCare plans did not explain fully how staff should meet the person's needs in their preferred way, including support in the community.
“Care plans lacked detail on how staff were to deliver care and treatment in the person's preferred manner.” from the report
Checks did not find every problem
needs fixingThe home's audits and improvement plans did not identify all the gaps found by inspectors, including missing risk assessments and outdated behaviour plans.
“However, not all areas identified within audits were consistent with the inspection finding.” from the report
- 01Have all fire risk assessment recommendations now been completed, and can you show us the current action plan?
- 02How do you now assess and record risks linked to behaviour, community travel and contact with animals?
- 03When was the positive behaviour management plan last reviewed, and how are changes shared with every staff member?
- 04How do the current care plans describe the person's preferences and the support needed during personal care and community activities?
- 05How do your audits now check that care plans, risk assessments and behaviour guidance are complete and up to date?
This was a planned inspection covering all five questions, but the inspector's time at the home was limited because the person could not tolerate unfamiliar visitors. This explanation was written from the published report of 20 April 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 View
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- May 2018Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- April 2017Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- January 2013
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- March 2011
Registered with the Care Quality Commission on 21 March 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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