CQC report explained · a residential care home
What the CQC found at Willowbrooke Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, April 2018
Rated Good; inspectors found safe, kind and responsive care, with improvements made after earlier concerns.
This was an unannounced inspection on 27 February 2018. Inspectors spoke with seven people living at the home, visitors, staff and health professionals. They reviewed six care records, staff training and recruitment records, and records about how the service was managed.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found improvements in risk management, medicines, consent and the systems used to monitor quality. People and relatives gave positive feedback about the care.
There were still some matters to improve. Care reviews for people staying temporarily or for respite did not always have enough records. Surveys were not formally analysed or reported back to people. There was also no registered manager in post at the time, although a new manager was applying to register.
Improved safety
Risk assessments had been introduced or reviewed, and the home had acted on concerns about falls. Inspectors also found better medicines management.
“We found improvements had been made in order to meet the regulations in relation to medicines management, and risk management and the provider was compliant in these areas.” from the report
Kind and respectful care
People were treated with kindness and compassion. Staff supported privacy, dignity and independence during everyday care.
“Our observations and our conversations with people showed that people were treated with kindness, respect and compassion, and that they were given emotional support when needed.” from the report
Personalised support and activities
Care plans generally reflected people's needs, preferences and desired outcomes. People were offered a range of activities, trips and exercise.
“The care plans were well written, comprehensive and person centred.” from the report
Stronger quality monitoring
The provider had introduced regular audits and external reviews. Shortfalls identified through these checks were usually dealt with promptly.
“We saw that audits had been undertaken in various areas such as medicines, health, staff files and care files.” from the report
Temporary stay records
needs fixingCare review records were not always present for people staying temporarily or receiving respite care. The manager said this would be reviewed.
“However, we noted that plans for people staying in the home on a temporary basis or on respite care did not always have care review records.” from the report
Survey feedback
needs fixingThe home acted on issues raised in surveys, but it did not formally analyse the results or give feedback to people. The provider said it would review this process.
“We noted that the questionnaire completed were not formally analysed and feedback given to people.” from the report
No registered manager at the visit
minorThe previous registered manager had left and there was no registered manager in post during the inspection. A new manager had applied to register.
“There was no registered manager employed at the home.” from the report
- 01How do you make sure care reviews are recorded for people staying temporarily or receiving respite care?
- 02How are survey results formally analysed, and how are the findings shared with residents and relatives?
- 03Who is currently managing the home, and has the manager's CQC registration application been completed?
- 04How are medicines audits carried out, and how quickly are any errors or shortfalls corrected?
- 05How are risks such as falls, weight loss and choking assessed and reviewed when people's needs change?
This was an unannounced inspection of the overall service, covering all five CQC question areas and checking progress against breaches identified at the March 2017 inspection. This explanation was written from the published report of 5 April 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, May 2017
Rated Requires Improvement; inspectors found kind and responsive care, but medicines, consent records and quality checks were not reliable enough.
This was an unannounced inspection over two days. Inspectors spoke with people living in the home, relatives, staff and health professionals. They observed care and checked care plans, medicine records, recruitment files, accident records and management systems.
People and relatives were very positive about the care. Inspectors found staff were kind, respectful and knew people's needs. Care plans had improved and people had access to healthcare, suitable food and activities. Staffing and recruitment arrangements were also suitable at the time of the inspection.
However, the home was not consistently safe, effective or well-led. Records for creams and thickening powders did not always show that medicines had been given. Mental capacity and consent records were incomplete. Environmental risks, including fire safety arrangements and low water temperatures, were not managed robustly. The home was in breach of Regulations 11, 12 and 17.
Kind and respectful staff
People and relatives spoke very positively about the staff. Inspectors saw staff protect privacy, treat people warmly and encourage independence.
“People told us the staff treated them with respect and kindness and were complimentary of the support they received.” from the report
Improved care planning
Care plans had improved significantly since the previous inspection. They included people's preferences, life histories, abilities and desired outcomes, and were reviewed regularly.
“The care plans were organised, detailed and clearly written.” from the report
Health and nutrition support
People's health needs were monitored and referrals were made to appropriate professionals. Dietary needs, preferences and risks of malnutrition and dehydration were recorded and monitored.
“People's nutritional needs were met.” from the report
Safeguarding awareness
Staff had current safeguarding training and understood how to recognise and report abuse. Safeguarding incidents had been referred to the relevant authority.
“The staff understood their role in safeguarding people from harm.” from the report
Suitable staffing and recruitment
Inspectors found staffing levels were sufficient for the people living in the home at the time. Required pre-employment checks had been completed for the files reviewed.
“We found the rotas indicated there were sufficient staff available for the 19 people who lived at the home.” from the report
Incomplete medicine records
seriousRecords did not always show that creams or thickening powders had been given as prescribed. Some cream records had gaps of up to five days, and these records had not been audited.
“This meant it was not possible to determine if the prescribed creams had been applied correctly or applied at all.” from the report
Fire and environmental risks
seriousThe building fire risk assessment and emergency lighting records were not available for inspection, and fire evacuation drills had not been carried out regularly. Some bedroom water temperatures were below safe limits and this had not been reported promptly.
“There was a lack of robust environmental risk management.” from the report
Consent and mental capacity records
seriousThe home had not formally recorded how it considered people's capacity to make decisions. Required consent forms had not always been signed, despite this concern also being found at the previous inspection.
“We concluded that the provider had failed to demonstrate that staff obtained consent lawfully.” from the report
Weak quality checks
seriousAudits did not cover several important areas, including care files, topical medicines, staff recruitment files, accidents and environmental checks. This meant problems were not identified before the inspection.
“Systems for assessing and monitoring the quality of the service were not robust.” from the report
Activities not seen during inspection
minorThe home had an activities coordinator and a programme of activities, but inspectors saw no activities on either inspection day because the coordinator was on leave.
“On the two days of the inspection, we observed there were no activities.” from the report
- 01How are creams and thickening powders recorded and checked now, and how do you confirm they are given as prescribed?
- 02How do you record mental capacity assessments and consent for people who cannot make particular decisions themselves?
- 03When was the building fire risk assessment completed, and how often are evacuation drills now carried out?
- 04What formal audits now cover medicines, care plans, accidents, recruitment records and environmental safety?
- 05What activities are available when the activities coordinator is away, and how are individual preferences reflected?
This was an unannounced comprehensive inspection covering all five key questions; the report's background section gives the visit dates as 15 and 17 February 2017, while the main summary gives 15 and 17 March 2017. This explanation was written from the published report of 18 May 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. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of Willowbrooke Residential Home
3 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- April 2018Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Willowbrooke Residential Home →
- May 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Willowbrooke Residential Home →
- January 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2015
Registered with the Care Quality Commission on 24 April 2015.
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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