CQC report explained · a nursing home
What the CQC found at Willowcroft Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, March 2022
Willowcroft Care Home was inspected but not rated; inspectors found good infection-control arrangements in some areas but gaps in distancing, cleaning checks and procedures.
This was an unannounced, targeted inspection on 24 February 2022. It looked mainly at infection prevention and control during a COVID-19 outbreak, and asked about staffing pressures.
Inspectors found good arrangements for visitor testing, protective equipment and COVID-19 testing. The home had enough protective equipment, and staff were observed using it in line with guidance.
Inspectors were only somewhat assured about social distancing, cleaning of frequently touched surfaces, checks on hand hygiene and protective equipment use, and the infection-control policy. The home said it would address these points.
The service was inspected but not rated. This means the visit did not give an overall quality rating or a full rating across all five areas.
Protective equipment
Staff were seen using protective equipment in line with government guidance, and the home had ample supplies.
“Staff were observed to be wearing Personal Protective Equipment (PPE) in line with current government guidelines, to ensure the safety of people supported, visitors and the staff team.” from the report
Testing arrangements
People living at the home and staff took part in the home’s testing programme.
“People using the service and staff took part in the home's testing programme.” from the report
Visitor controls
Visitors were tested before visits and given protective equipment. Visiting arrangements followed outbreak advice from the local authority and Public Health England.
“All visitors were required to carry out rapid COVID-19 test prior to the visit and were provided with personal protective equipment (PPE).” from the report
Social distancing
needs fixingThere were no clear arrangements to reduce close contact when social distancing was needed. Some people who tested positive could still use communal areas because of their mental health needs.
“There were no clear protocols to mitigate and minimise the risk of close contact between people or to promote social distancing when it was required.” from the report
Cleaning records
needs fixingThe home looked clean, but there were no records showing that frequently touched surfaces such as door handles and handrails were regularly cleaned and disinfected.
“There were no records to confirm frequently touch points, such as door handles or handrails, were regularly cleaned and disinfected.” from the report
Checks on staff practice
needs fixingThe home did not have processes to check good hand hygiene or whether staff put on and removed protective equipment correctly.
“There were no processes in place to ensure staff were following good hand hygiene practice or checking whether staff had donned and doffed their PPE correctly.” from the report
Out-of-date policy
needs fixingThe infection-control policy was generic and did not reflect the latest government guidance or the home’s own arrangements.
“This document had not reflected the latest government guidance and was not service specific.” from the report
- 01What changes have you made to manage communal-area access when someone has COVID-19 but cannot self-isolate?
- 02How do you now record cleaning of frequently touched surfaces such as door handles and handrails?
- 03How do you check staff hand hygiene and their correct use of protective equipment?
- 04Has the infection-prevention policy been updated to reflect current guidance and the home’s own arrangements?
- 05How are visits managed during a COVID-19 outbreak, and what alternatives are offered when only essential visits are allowed?
This was an unannounced targeted inspection of infection prevention and control and staffing pressures during a COVID-19 outbreak; it did not provide a full rating of the home. This explanation was written from the published report of 15 March 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, February 2021
Rated Good; inspectors found kind, safe care, but some moving and handling and medicines records needed attention.
This was an unannounced focused inspection carried out over 15 and 30 December 2020. It followed concerns about the quality of care at night. Inspectors spoke with staff, relatives and professionals, and reviewed care, medicines, recruitment and management records.
The home was rated Good overall. Safe, caring and well-led were rated Good. Inspectors found enough staff, good risk management, well-managed medicines and infection control, and kind, person-centred support.
Inspectors observed one incident of poor moving and handling practice. They also found some inconsistencies in records for medicines given as needed, hidden medicines and skin patches. The manager was already working to address these issues.
Effective and Responsive were not inspected during this visit. Their previous ratings were used in the overall rating.
Kind, person-centred care
Staff took time to understand people and built strong relationships with them. They supported personal choices, dignity and independence.
“People received very kind and caring support by staff who took the time to get to know them.” from the report
People kept safe
Staff understood safeguarding and individual risks. There were enough staff to meet people's needs, and incidents were reviewed so lessons could be learned.
“Potential risks to people were identified, assessed, monitored and managed well.” from the report
Good management oversight
The provider and managers worked together, used audits and carried out checks, including at night. Staff received feedback and training.
“There was a strong framework of accountability within the home.” from the report
Family involvement
The home kept relatives informed during the pandemic and continued care reviews and online meetings. Relatives said management was approachable.
“Relatives found management to be very approachable and helpful.” from the report
Infection control
Inspectors were assured that the home had arrangements to prevent and manage infections, including coronavirus outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Moving and handling practice
needs fixingInspectors saw one incident of poor moving and handling practice. This was reported to the manager during the inspection and addressed with staff.
“We did observe one incident of poor moving and handling practice, which we fed back to the registered manager on the day of the inspection and they addressed this with staff.” from the report
Medicines records
needs fixingPeople received their medicines safely, but some records were inconsistent. The issues involved medicines given as needed, hidden medicines and skin patches.
“We did find some inconsistencies in documentation. Particularly around PRN protocols, covert medicines and the administration of topical medicines such as patches.” from the report
- 01What action was taken after the poor moving and handling practice observed during the inspection?
- 02How have you checked that all staff now follow the correct moving and handling procedures?
- 03Have the inconsistencies in records for as-needed, hidden and skin-patch medicines been fully corrected?
- 04How do you check the quality of care provided at night?
- 05What were the previous ratings for Effective and Responsive, which were not inspected this time?
This was a focused inspection of Safe, Caring and Well-led following concerns about night-time care; Effective and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 9 February 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.
Every inspection of Willowcroft Care Home
4 rated inspections over 4 years: the service has held its Good rating throughout.
- March 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- February 2021Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2019Goodstayed GoodSafe: GoodCaring: OutstandingWell-led: Good
- April 2017Goodstayed GoodSafe: Requires improvementWell-led: Good
- December 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Registered with the Care Quality Commission on 21 July 2014.
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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