CQC report explained · a residential care home
What the CQC found at Willowdene
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People had individual risk assessments, enough staff and a clean environment. However, medicines checks were not robust enough to identify some minor discrepancies.
- Effective?
- Good
- Staff assessed people's needs, had suitable training and worked with health and social care professionals. People were supported with food choices, communication and health information.
- Caring?
- Good
- Staff treated people with respect and supported choice, control and independence. Inspectors noted that staff knew people well and used different ways to understand their wishes.
- Responsive?
- Good
- Care plans were detailed and personalised. Staff supported people's routines, communication needs, interests and relationships, and information about complaints was available in an easy-read format.
- Well-led?
- Good
- The home had a clear, person-centred vision and good informal oversight. Formal audits and policies did not always recognise the specific nature and risks of a respite service.
What inspectors found, November 2019
Willowdene was rated Good overall; inspectors found caring, person-centred support, but medicines checks and quality monitoring needed strengthening.
Inspectors visited on 22 October 2019. One inspector observed support, spoke with four staff, one relative and two health professionals, and reviewed care, medicines and management records. They also used information from a separate review of the provider's quality monitoring processes.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, clean surroundings, suitable training, kind support and detailed care plans. Staff knew people well and worked with families and other professionals.
There were some shortfalls. Medicines systems did not identify minor discrepancies, and the provider's audits did not fully reflect the particular risks of a short-break service. Inspectors made a recommendation to improve policies, procedures and quality checks. No regulation was recorded as breached.
Enough, consistent staff
Staffing was adjusted to people's individual needs. Staff supporting people were familiar with them and knew their support requirements.
“People were supported by enough staff who knew them well.” from the report
Person-centred support
Staff understood people's routines, interests, communication methods and preferences. Support plans contained detailed personal information to help staff provide consistent care.
“Support plans were detailed and provided person centred individual detail.” from the report
Choice and independence
Staff supported people to make decisions and work towards greater independence. The service used positive behaviour support and aimed to use the least restrictive approach.
“People were supported to identify goals they wanted to achieve and improve their independence.” from the report
Good partnership working
Staff communicated with families and worked with health and social care professionals. Communication books and hospital passports helped share important information.
“Staff worked with other health and social care professionals to understand and meet the needs of people using the service.” from the report
Medicines checks
needs fixingThere were no regular day-to-day medicine audits. The existing system missed some minor discrepancies, so the provider said it would strengthen its checks.
“We found the system in place was not robust enough to identify some minor discrepancies in the person's medicines.” from the report
Quality monitoring did not fit the service
needs fixingThe provider's audit tool was designed for supported living and was not always suitable for this short-break service. Inspectors recommended reviewing policies, procedures and systems.
“We recommend the provider review their policies, procedures, and systems to ensure they recognise and fully support the specific nature of the short-term respite service provided.” from the report
Some goals were not clearly followed up
minorOne person's independence outcome had been identified but there was no clear evidence of further work on it. Inspectors were also unclear how regularly outcomes were reviewed.
“However, it was not clear how regularly these outcomes were reviewed and implemented.” from the report
- 01What changes have you made to the day-to-day medicines audits since inspectors found minor discrepancies were not identified?
- 02How have you changed your quality checks so they reflect the particular risks of a short-break service?
- 03How will you review and follow up my relative's independence goals during and after each stay?
- 04How will you keep my relative's usual routines, communication methods and support approaches consistent during a short stay?
- 05How do you record and share important information with families and other services when people move in and out of the home?
This was the first inspection of the newly registered service and covered all five CQC questions; it also used a separate provider quality-monitoring review carried out on 16 September 2019. This explanation was written from the published report of 26 November 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 Willowdene
Each visit the CQC has published, newest first, back to the day the home was registered.
- November 2019Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2018
Registered with the Care Quality Commission on 16 May 2018.
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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13 live-in carers within about an hour of Norfolk
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.