CQC report explained · a nursing home
What the CQC found at Willowbank Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, November 2023
Rated Inadequate and placed in special measures; inspectors found people at risk from unsafe care, poor staffing and weak management.
This was an unannounced inspection prompted by concerns about risks, medicines, staffing and complaints. Inspectors visited on 9, 17 and 23 January 2023. They observed care, spoke with people, relatives and staff, and checked care, medicine, recruitment and management records.
The overall rating was Inadequate. Safe, Responsive and Well-led were also rated Inadequate. Inspectors found risks to health, wounds, nutrition, moving and handling, fire safety and medicines were not managed reliably. There were not enough staff, recruitment checks were incomplete, and care plans did not consistently reflect people's needs or preferences.
Inspectors did find some safer practices. People said they felt safe, staff understood safeguarding, infection control arrangements were satisfactory, and staff were kind when providing care. However, widespread failures remained, including poor complaint handling and ineffective checks by the provider. The home was already rated Requires Improvement in February 2021 and remained in breach of regulations.
Safeguarding
People told inspectors they felt safe. Staff understood safeguarding procedures and said they were confident concerns would be dealt with appropriately.
“Staff understood safeguarding procedures and had received safeguarding training.” from the report
Infection control
Inspectors were assured that infection prevention arrangements covered visitors, admissions, protective equipment, outbreaks and cleaning practices.
“We were assured that the provider was responding effectively to risks and signs of infection.” from the report
Kind interactions
Inspectors saw staff treating people kindly. People described staff as caring, good and courteous, although staffing shortages affected the support available.
“We observed staff were kind and caring when interacting with people.” from the report
End of life support from specialists
The home worked with palliative care specialists to help some people have a comfortable death. One relative also described the support before and after a death as very good.
“They worked closely with other professionals including palliative care specialists to make sure people had a pain-free and comfortable death.” from the report
People were at risk of harm
seriousHealth and wellbeing risks, including wounds, nutrition and moving and handling, were not consistently assessed or managed. Fire safety risks identified in 2022 had not been addressed.
“Systems were not robust enough to demonstrate safety was effectively managed. This placed people at risk of harm.” from the report
Not enough staff
seriousPeople waited for help, including more than 25 minutes after using a call bell. Staff said care was rushed and they did not have enough time to meet people's needs.
“There were not enough suitable staff to meet people's needs and keep them safe.” from the report
Medicines were not always safe
seriousThere were gaps in guidance for medicines given when needed, records for thickening powder were unclear, and the correct interval was not always kept between some paracetamol doses.
“We found no evidence that people had been harmed, however, people were placed at risk of harm by the failure to ensure the safe and proper management of medicines.” from the report
Care plans did not reflect people's needs
seriousSome care plans lacked personal information or current guidance. Planned showers were not always provided, and one person's records showed no bath or shower between October 2022 and the inspection.
“Care was not planned and delivered in a way to meet people's needs.” from the report
End of life planning
seriousPeople's wishes and preferences for end of life care were not recorded or discussed. Some rooms were not cleaned promptly after people had died.
“People's end of life care was not planned to meet their wishes and preferences.” from the report
Poor complaint handling and oversight
needs fixingA complaint had not been investigated or answered despite repeated follow-up. The provider's audits and management systems did not identify or resolve widespread problems.
“Complaints were not dealt with in an open and transparent way.” from the report
- 01What has been done to make staffing levels safe, and what are the current call-bell response times?
- 02How are wounds, nutrition, moving and handling risks, pressure mattresses and fire safety now checked and acted on?
- 03How do you make sure medicines, including medicines given when needed and thickened fluids, are recorded and administered correctly?
- 04How are care plans now written with people and their relatives, and how do you check that planned personal care is delivered?
- 05What action has been taken on unanswered complaints, and how will families receive clear responses within agreed timescales?
This was a focused inspection prompted by concerns and rated Safe, Responsive and Well-led; Effective and Caring were not inspected in this report and their ratings were not given. This explanation was written from the published report of 2 November 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 2022
Inspected but not rated; inspectors found strong infection control, clean premises and safe arrangements for visits.
This was a targeted inspection on 10 January 2022. It focused on infection prevention and control during the COVID-19 pandemic, and on whether staffing pressures affected care. The inspection was announced one day in advance.
Inspectors found clear infection control signs, a very clean home, cleaning records and correct use of personal protective equipment. The home was carrying out regular testing for staff and residents. Inspectors were assured that visitors, new admissions, social distancing and infection outbreaks were being managed safely.
The home was also facilitating visits, Skype calls and window visits. Agency staff had been used when needed to manage COVID-19 staffing pressures. The service was meeting the requirement to check that non-exempt staff and visiting professionals were vaccinated. The service was inspected but not rated, so this report does not give a full quality rating.
Clean home
The home was very clean and inspectors saw cleaning records supporting the cleaning process.
“The home was very clean. We saw evidence of cleaning records to support the cleaning process around the home.” from the report
Infection control
Inspectors saw clear infection control information, correct PPE use and evidence of regular testing for staff and residents.
“We saw prominent and clear infection prevention control (IPC) signs reminded everyone at the point of entry and throughout the home about procedures for infection control.” from the report
Family contact
The home had assessed visitor risks and continued visits through different arrangements, including Skype calls and window visits.
“Risks in relation to visitors had been assessed and action taken to ensure visits were still in place at the service and through skype calls as well as window visits.” from the report
Staff support
Staff reported being supported during the pandemic and kept up to date with changes in government guidance.
“Staff said they had been well supported by the registered manager during the pandemic and had been kept up to date with all the Government changes in guidance.” from the report
Inspectors raised no specific concerns in this report.
- 01How are you currently managing staffing pressures, and how often are agency staff being used?
- 02How do you currently check PPE use, testing and infection control in the home?
- 03How can relatives visit, and what alternatives are available if an in-person visit is not possible?
- 04How do you check that visiting professionals meet the current COVID-19 vaccination requirements or have an exemption?
- 05How do you safely manage new admissions and any infection outbreaks?
This was a targeted inspection of infection prevention and control and COVID-19-related staffing pressures; it was not a full assessment of the other four questions and the service was inspected but not rated. This explanation was written from the published report of 2 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.
Every inspection of Willowbank Nursing Home
4 rated inspections over 8 years: the service has slipped, from Good to Inadequate.
- November 2023Inadequatecurrent ratingSafe: InadequateEffective: GoodCaring: GoodResponsive: InadequateWell-led: Inadequate
- February 2022Inspected but not ratedSafe: Inspected but not rated
- February 2021Requires improvementdown from GoodSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2018Goodstayed GoodSafe: GoodResponsive: Requires improvementWell-led: Good
- January 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 11 November 2010.
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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