CQC report explained · a nursing home
What the CQC found at Willows Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found suitable staffing levels, safe recruitment, infection control measures and systems for managing risks, incidents and medicines. They noted that more detailed stoma care plans were needed and said immediate action was taken.
- Effective?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward.
- Caring?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward.
- Responsive?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward.
- Well-led?
- Good
- Inspectors found an open and positive culture, regular audits, staff meetings and opportunities for people and relatives to give feedback. They found that management acted on identified improvements.
What inspectors found, January 2021
Rated Good; inspectors found safe care and positive management, although some care plans needed updating.
This was an unannounced focused inspection in December 2020. Inspectors visited the home, spoke with people, relatives and staff, and checked care records, medicines records, staff files and management records.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, safe recruitment, suitable infection control measures and safe medicines systems. They also found that risks, incidents and complaints were monitored.
The inspection followed concerns about staffing, infection control, medicines, management and the culture of the home. Inspectors did not confirm these concerns. Some improvements had been identified, including better communication and more detailed planning for certain care needs.
Only Safe and Well-led were inspected during this visit. The other ratings from the previous comprehensive inspection were carried forward when calculating the overall Good rating.
Safe staffing
The home used dependency information to plan staffing and inspectors saw the correct number of staff on shift. People requiring one-to-one support were observed receiving it.
“We checked staff rotas and saw the correct number of staff on shift.” from the report
Medicines checks
Medicines were stored, administered and recorded safely at the inspection. Errors had been investigated, with retraining and competency checks used to reduce the chance of them happening again.
“We were assured the management team had identified errors immediately, took action to check people were safe and learned from lessons to minimise reoccurrence.” from the report
Positive management
Inspectors found that people, relatives and staff were generally positive about the management team. Staff could raise concerns and the home used audits and feedback to identify improvements.
“We found nearly all staff, people and relatives we spoke with were very positive about the service and the management team.” from the report
Infection control
Inspectors were assured that the home was following infection control, testing, shielding and social distancing arrangements during the Covid-19 pandemic.
“We were assured that the provider was using Personal Protective Equipment (PPE) effectively and safely.” from the report
Some care plans needed more detail
needs fixingThere were not always specific assessments for certain care needs, including stoma care. Inspectors discussed this with the nursing staff and manager, who took immediate action to develop the plans.
“However, there were not always specific assessments for certain types of care need such as stoma care, to help people with toileting.” from the report
Recent medicine errors
needs fixingBefore the inspection, the home had reported repeated medicine errors. Inspectors found that these had been investigated and addressed, but families may want to ask how the improvements are being maintained.
“Prior to our inspection, the provider had notified us of repeated medicine errors and informed us of the action they had taken to investigate these incidents.” from the report
Further communication improvements planned
minorThe home had plans to improve two-way communication and the key worker and named nursing staff arrangements. Families may wish to ask what progress has been made.
“We could see there were plans to ensure there was more effective two way communication, such as having more people and staff coffee mornings and improve the key work and named nursing staff system.” from the report
- 01How do you now assess and review stoma care and other specific care needs?
- 02What changes were made after the repeated medicine errors, and how do you check that medicines remain safe?
- 03Have staffing levels remained stable since the inspection, including during staff absences?
- 04What progress has been made with two-way communication, key workers and named nursing staff?
- 05How are relatives currently involved in meetings, feedback and decisions about the home?
This was a focused inspection of Safe and Well-led only; the other ratings from the previous comprehensive inspection were carried forward. This explanation was written from the published report of 22 January 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
Rated Good; inspectors found safe, kind and personalised care, with some meal-time, staffing and record-keeping issues to watch.
This was an unannounced inspection on 11 April 2019. Inspectors reviewed care records, medicines, staff training and recruitment, audits, complaints, accidents and safety checks. They spoke with people living in the home, relatives, staff and managers.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were protected from abuse, received medicines as prescribed, had access to health professionals and were supported by trained staff. Care was described as kind, respectful and tailored to people's needs.
The home had improved from Requires Improvement at the inspection in February 2018. Earlier concerns about caring, responsiveness, leadership and catering had been addressed, although inspectors still noted some inconsistencies at meal times, mixed views about staffing and a gap in one medicines record.
People felt safe
People and relatives said the home was safe. Staff understood how to recognise and report abuse.
“People were safe in the home and there were procedures to protect them from abuse.” from the report
Prompt response to call bells
Records showed that staff responded promptly when people used their call bells. Inspectors found the staffing numbers on duty were sufficient at the time.
“Records confirmed that staff always responded within three minutes, as required and showed that staffing levels were sufficient in the home.” from the report
Kind and respectful care
Inspectors observed staff being polite, patient and considerate. People were supported to keep their independence and privacy.
“We observed staff to be polite and patient towards people. They approached them in a way that was considerate of their needs.” from the report
Personalised care plans
Care plans included people's backgrounds, preferences and support needs. They were reviewed when needs changed or at least monthly.
“Care plans were personalised and contained comprehensive information on people's backgrounds, histories, likes and dislikes.” from the report
Improved complaints handling
The home had a complaints process and inspectors saw evidence that complaints were acknowledged, investigated and answered.
“There was a complaints procedure and we saw that all complaints were acknowledged and addressed by the registered manager.” from the report
Mixed views about staffing
needs fixingOne person said there were not enough staff on their ward, while others felt staffing was sufficient. The home used agency staff when needed and inspectors found the required numbers on duty.
“100% not enough staff on this ward. Has a lot of demanding people on it.” from the report
Medicines record gap
needs fixingA daily topical cream had not been entered on the current medicines administration record. A new record was created during the inspection, and managers said they would review the process.
“However the management team told us they would look into reviewing this procedure and ensure that the new MAR sheet is created earlier in the week, as it had been four days since the end of the previous MAR sheet.” from the report
Meal times were not consistent
needs fixingInspectors saw music and interaction in two units but less interaction in another. Menu cards also did not always accurately show the meal served.
“However, the other unit was quiet and there was less interaction between people and staff.” from the report
A damaged bed was awaiting repair
minorOne relative said a damaged bed had not been repaired despite being reported. The bed was repaired after inspectors raised the issue.
“However, one relative told us that their family member's bed was damaged and had yet to be fixed, despite it being reported to the management team.” from the report
- 01What staffing levels are normally provided on the unit my relative would use, and how do you respond when staff are absent?
- 02How do you make sure every medicine, including topical creams, is recorded on the medicines administration record without gaps?
- 03What changes have you made to make meal times equally interactive and consistent across all units?
- 04How quickly are repairs to beds and other equipment normally completed after they are reported?
- 05How have you maintained the improvements made since the Requires Improvement inspection in February 2018?
This was an unannounced planned inspection covering all five CQC questions and the overall quality of the home. This explanation was written from the published report of 9 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 Willows Care Home
6 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- January 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- April 2018Requires improvementdown from GoodSafe: GoodEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015Requires improvementstayed Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- May 2015Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2014
Registered with the Care Quality Commission on 2 September 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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