CQC report explained · a nursing home
What the CQC found at Willowbeck Health Care Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, June 2021
Rated Requires Improvement; inspectors found people felt safe and received effective care, but safety records, medicines and management checks were not reliable enough.
This was an unannounced focused inspection on 21 April 2021. Inspectors looked at Safe, Effective and Well-led. They spoke with people, relatives and staff, and checked care records, medicines, staff files and management records.
The home was rated Requires Improvement overall. Safe and Well-led were Requires Improvement. Inspectors found missing or incomplete risk information, medicines errors and maintenance issues. Management checks had not found these problems or shown that previous lessons had been fully acted on.
Effective was rated Good. People had access to healthcare, staff received training, and people were supported with food, choices and decisions. People and relatives generally said they felt safe and spoke positively about the staff and manager.
The previous overall rating was Good, published in May 2019. Caring and Responsive were not inspected during this visit, so earlier ratings for those areas were carried forward.
People felt safe
People and relatives generally said they felt safe and were positive about how staff supported them.
“My [relative] looks and feels happy and safe in the environment” from the report
Access to healthcare
Records showed timely communication with health professionals, and people were supported to attend appointments and receive ongoing healthcare.
“People's records showed communication with health professionals was effective and timely.” from the report
Staff training
Staff received ongoing training, supervision and appraisals. Training completion was high and well monitored.
“Staff were given opportunities to review their individual work and development needs.” from the report
Choice and legal rights
People were supported to make day-to-day decisions, and records showed the home was following Mental Capacity Act and DoLS requirements.
“People's records contained examples of how people were supported within MCA requirements” from the report
Communication with families
Relatives said they were kept informed and were involved when things went wrong or when other services were needed.
“The (staff) take time out to keep you informed on everything, and I mean everything, that happens” from the report
Incomplete risk information
seriousSome support plans did not explain risks or give staff enough detail about how to support people safely. Information was not always updated consistently.
“In some instances, support plans did not contain information about risks to people's health.” from the report
Medicines errors and records
seriousFrequent medicines errors had occurred. Some records did not explain changes to medicines, and supervised self-administration was not recorded.
“The medicines administration records contained all the necessary information for the safe administration of people's medicines however frequent medicines errors had regularly taken place.” from the report
Management checks missed problems
seriousAudits and other checks had not identified the safety concerns found during inspection or shown that learning from earlier incidents was effective.
“However, these checks had not identified the concerns we found during our inspection visit.” from the report
Support for new staff
minorNew staff could ask experienced colleagues for help, but formal support for new staff was not in place at the time of inspection.
“it was evident formal support for new staff was not in place” from the report
- 01What has changed to make sure every person's risk assessment and support plan gives staff enough detail to keep them safe?
- 02How are medicines errors now investigated, reduced and checked, including recording supervised self-administration and changes to as-and-when medicines?
- 03Have the air-conditioning units in the two medicine rooms been repaired, and how are maintenance issues now followed up?
- 04How does the home check that lessons from accidents, incidents and medicines errors have been put into practice across all units?
- 05What formal support is now provided to new staff, and how are staffing shortages and missed breaks being managed?
This was an unannounced focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 9 June 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.
What inspectors found, May 2019
Willowbeck Health Care Limited rated Good; inspectors found safe, kind and personalised care, with some bathroom access and staffing issues to keep under review.
This was a planned inspection on 11 and 12 April 2019. The first day was unannounced. The inspector spoke with six people, nine staff, the manager and senior managers. They observed care and checked care records, staff files and management information.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were protected from harm, received personalised care and were treated with warmth, dignity and respect. People were involved in their care and in the running of the home.
The report also identified some matters being addressed. Some en suite bathrooms were too small for certain wheelchairs, one communal area was cramped, and staff reported occasional shortfalls caused by sickness. The manager was applying to register with CQC, and the home was sourcing extra end of life care training.
Personalised independence
People helped plan their care and were supported to make choices and develop skills. Staff focused on helping people do as much as possible for themselves.
“The care is exceptional, staff know me well and know what I want to be doing; they help me to achieve what I want to.” from the report
People's involvement
Resident ambassadors gathered feedback and discussed it with managers. People also helped with recruitment, the design of the home and practical roles such as running a snack shop.
“People using the service had been involved in recruitment of new staff, as well as in planning the design and décor of the home.” from the report
Safe care systems
Inspectors found detailed and regularly reviewed risk assessments, trained staff and safe medicines management.
“Each care plan we checked contained detailed assessments of any risk that the person may be vulnerable to or may present.” from the report
Visible management
Managers visited every unit daily and used audits and meetings to monitor care, risks and improvements.
“There was a range of comprehensive audit systems in place, which were carried out regularly and to a thorough standard.” from the report
Activities and choice
The home offered varied activities and worked to support individual interests and wishes.
“There was a comprehensive activities programme within the home and people using the service told us this was important to them.” from the report
Wheelchair access
needs fixingSome en suite bathrooms were too small for certain types of wheelchairs. The manager was aware and said improvements were being sought.
“Two people using the service told us, and one showed us, that some of the en suite bathrooms were too small to be used with certain types of wheelchairs.” from the report
Cramped communal area
minorOne communal area was considered cramped. Plans were underway to add another communal area in that unit.
“The home manager told us they had identified one communal area of the home was quite cramped for the people using it, therefore plans were underway to add an additional communal area in that unit, to better meet people's needs.” from the report
Occasional staffing shortfalls
needs fixingStaff said there were usually enough people on duty, but some reported occasional shortfalls when colleagues were off sick.
“Staff said there were usually enough staff available, although some mentioned there were occasional shortfalls due to sickness.” from the report
Manager registration
minorThere was no manager registered with CQC at the time of the inspection. The manager was submitting an application to register.
“The service did not have a manager registered with the Care Quality Commission, we saw evidence, however, that the home's manager was in the process of submitting an application to CQC to register.” from the report
- 01What improvements have been made to the en suite bathrooms for people using wheelchairs?
- 02Has the additional communal area been created in the unit where space was cramped?
- 03How do you cover shifts when staff are absent through sickness?
- 04Has the manager's CQC registration application been completed?
- 05What end of life care training have staff received since the inspection?
This was a planned inspection covering the premises and care provided, with ratings given for all five CQC questions; the first day was unannounced. This explanation was written from the published report of 10 May 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 Willowbeck Health Care Limited
3 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- June 2021Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Willowbeck Health Care Limited →
- May 2019Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
Read what inspectors found at Willowbeck Health Care Limited →
- October 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2014
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 21 January 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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