CQC report explained · a nursing home
What the CQC found at Willows Lodge Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2023
Rated Requires Improvement; inspectors found risks with safety, staffing, medicines, nutrition and management systems.
This was an unannounced inspection. Inspectors visited on 23 August 2023 and also carried out inspection activity between 22 and 31 August. They spoke with people, relatives and staff, and checked care, medicines, staffing and other records.
The home was not always safe or effective. Inspectors found problems with medicines, infection control, call bells, equipment, staffing, staff training, supervision and support with food and drink. Care records did not always contain the right, up-to-date information.
People and relatives described staff as caring and kind, but people's experiences varied. Care was often task-led rather than person-centred, and people were not always supported with activities that suited their needs.
The overall rating changed from Good at the previous inspection, published in January 2020, to Requires Improvement. This means the report found limited assurance about safety and that improvements were needed.
Kind relationships
People and relatives said staff treated them with care and kindness. Inspectors also saw positive relationships between people and staff.
“People and their relatives told us they were treated with care and kindness.” from the report
Learning from incidents
Managers investigated accidents and incidents, and staff discussed lessons learned to improve people's care.
“The service managed accidents and incidents affecting people's safety well. Staff recognised incidents and reported them appropriately and managers investigated incidents.” from the report
Healthcare links
The home worked with healthcare and social care professionals, including the GP, pharmacy and local services.
“The provider worked in partnership with a number of different health and social care professionals including the local authority and local healthcare services.” from the report
Open visiting
Relatives were able to visit without restrictions and said they could visit whenever they wanted.
“We can visit whenever we want to. There is an open-door policy. We don't have to tell them we are coming to visit [relative].” from the report
Safety and medicines
seriousInspectors found medicines stored unsafely, incomplete medicines records, missing reviews of some as-needed medicines, and risks that were not always recorded or managed. A warning notice was served for the safe care and treatment breach.
“Systems had not been established to ensure care and treatment was provided in a safe way for service users. This placed people at risk of harm.” from the report
Staffing and response times
seriousStaff deployment did not match people's needs. Inspectors saw long waits for help, including a call bell that rang for 32 minutes.
“A call bell was buzzing for 32 minutes and an inspector had to inform a member of staff to attend.” from the report
Food and drink support
seriousPeople were not always given timely help to eat and drink. Inspectors found inconsistent fluid records and a person at risk of malnutrition and dehydration was left without the required support.
“We found no evidence that people had been harmed however, systems were either not in place or robust enough to demonstrate people were supported to meet their nutritional and hydration needs.” from the report
Infection control
needs fixingInspectors found unhygienic areas, poorly stored equipment and problems with handwashing and protective equipment. These created infection prevention risks.
“The laundry room, bathrooms and trollies were unhygienic.” from the report
Person-centred care
needs fixingSome care plans were generic or out of date and did not give staff enough information about people's needs, history and preferences. People were not supported with regular activities that met their needs.
“People were not supported or enabled to take part in regular social activities that met their needs.” from the report
Management checks
seriousThe home's quality checks did not identify several problems. Records and action plans were incomplete, and a warning notice was served for the good governance breach.
“The quality assurance and governance arrangements in place were not always effective in identifying shortfalls in the service.” from the report
- 01What has been done to make medicines storage, temperature checks, MAR records and as-needed medicine protocols safe and reliable?
- 02How many staff are on each unit at different times, and how will you make sure call bells and personal care needs are answered promptly?
- 03How are nutrition, hydration and fluid records checked for people at risk of malnutrition or dehydration?
- 04How are care plans and risk assessments now kept accurate, personalised and up to date?
- 05What action has been taken following the warning notices, and how can families see evidence of progress?
This inspection covered Safe, Effective and Well-led; the report says ratings for key questions not inspected were carried over from the previous inspection. This explanation was written from the published report of 10 October 2023 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, January 2020
Rated Good overall; inspectors found kind, responsive care, but medicines and some safety checks needed improvement.
This was an unannounced inspection over three visits. Inspectors spoke with 15 people, eight relatives and eight staff. They reviewed care files, staff records, medicines records and the home's quality checks.
The home was rated Good overall. Effective, caring, responsive and well-led were all rated Good. People described kind care, good relationships with staff, suitable activities, enough food and access to healthcare.
Safe was rated Requires Improvement. Inspectors found medicines were not always given as prescribed, some recruitment checks were incomplete and some risks were not properly assessed. These included unsecured wardrobes and out-of-date evacuation plans. The home took immediate action on some issues, and said several other improvements were completed after the inspection.
Kind and respectful care
People and relatives spoke positively about the care. Inspectors saw staff treating people with kindness, empathy, dignity and respect.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Good mealtime support
People could choose where to eat and were not rushed. Staff offered alternatives and supported people in a dignified way.
“The dining experience for people was positive. People were not rushed to eat their meal and where they required staff assistance this was provided in a dignified and respectful manner.” from the report
Healthcare support
People could access healthcare services when needed. Relatives said they were kept informed about their family member's health needs.
“People had access to healthcare services when they needed it and confirmed their healthcare needs were met.” from the report
Activities and social contact
The home offered group and one-to-one activities, outside visits and opportunities for religious observance. People could also maintain relationships with relatives.
“Opportunities were given for people to access the local community. Activities included laying a wreath for the upcoming Remembrance Sunday in the town square, visiting a local garden centre and going to the pub for a drink.” from the report
Accessible management
People, relatives and staff said the manager was approachable and supportive. Staff felt able to raise concerns.
“People, and those acting on their behalf were complimentary regarding the registered manager. Relatives told us there was a positive culture within the service and the registered manager was visible and approachable.” from the report
Medicines were not always managed safely
seriousSome medicines were given more or less often than prescribed. Four people's records had gaps where staff had not signed to show medicines were administered.
“Medication Administration Records [MAR] showed not all people using the service received their prescribed medication as they should.” from the report
Some safety risks were missed
seriousTen freestanding wardrobes were not secured to the wall and some personal evacuation plans contained inaccurate information. The home said these issues were corrected quickly after inspectors raised them.
“Not all environmental risks to people using the service had been identified. For example, we found ten freestanding wardrobes were not secured to the wall.” from the report
Recruitment checks were incomplete
needs fixingSome staff files did not fully record employment history or reasons for leaving previous jobs. References were also missing or incomplete in some files.
“Staff recruitment practices were not operated in line with the provider's own policies and procedures and improvements were required.” from the report
Care records were not always current
needs fixingSome care plans contained contradictory information about people's mobility or skin condition. End of life plans did not always include personal cultural or spiritual preferences.
“We found some people's care plans were not up to date and contained contradictory information.” from the report
Communication materials could be clearer
minorMenus were not in easy-read or large-print format, and pictorial cards were not used to help some people choose meals.
“More could be done to effectively apply the AIS standards, for example, although the activity programme was provided in an easy read and large print format, this was displayed on a large board and referred to lots of information, which some people may find difficult to decipher and understand.” from the report
Quality checks did not find all problems
needs fixingThe home's monitoring systems had not identified the medicines, record-keeping and staff issues found during the inspection. The provider acted on the issues once they were raised.
“However, improvements were required to ensure the quality assurance process identified issues we found at this inspection, such as medication practices, some aspects of record keeping and issues relating to staff.” from the report
- 01How do you now check that every medicine, including creams and pain relief, is given exactly as prescribed and recorded correctly?
- 02What checks are now completed before staff start work, including employment history and references?
- 03How are care plans kept up to date when a person's mobility, skin condition or end of life wishes change?
- 04What percentage of staff have now completed fire drills using evacuation equipment, especially night staff?
- 05How do you make menus and activity information accessible for people who need easy-read, large-print or pictorial information?
This was an unannounced comprehensive inspection covering all five key questions, the premises and the care provided. This explanation was written from the published report of 17 January 2020 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 Lodge Care Home
5 rated inspections over 8 years: the service has improved, from Inadequate to Requires improvement.
- October 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2020Goodstayed GoodSafe: Requires improvementEffective: GoodWell-led: Good
- May 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2016InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- July 2015
Registered with the Care Quality Commission on 20 July 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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