CQC report explained · a residential care home
What the CQC found at Willowthorpe Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found safe recruitment, safeguarding training, regular reviews of staffing needs, safe medicines management and appropriate infection control. They also found that accidents and incidents were monitored.
- Effective?
- Good
- People were supported with food, healthcare and daily choices. Staff had relevant training and worked in line with the Mental Capacity Act, although staff supervision still needed improvement.
- Caring?
- Good
- Inspectors found kind and compassionate support from staff who knew people well. People's privacy, dignity, choices and involvement in care planning were respected.
- Responsive?
- Good
- Care was planned around people's needs and preferences. People were supported with activities, relationships and end of life wishes, and complaints were dealt with in line with the home's policy.
- Well-led?
- Requires improvement
- The home had audits, action plans and a manager who was viewed positively by people and staff. However, one care plan contained conflicting hoist instructions and did not clearly record why changes had been made.
What inspectors found, January 2019
Rated Good overall; inspectors found kind, safe care, but the well-led rating Requires Improvement because some care records were not accurate.
Inspectors visited without notice on 28 and 29 November 2018. They spoke with people living in the home, relatives, staff and managers. They also checked care plans, staff files, audits and other records.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found suitable recruitment, trained staff, safe medicines practice, support with food and health needs, kind care, meaningful activities and a complaints process that worked.
The Well-led rating was Requires Improvement. One care plan gave conflicting instructions about using a hoist, including the sling size and the correct hoops. The report says improvements had been made since the previous inspection in August 2017, but care records still needed to be kept accurate and up to date.
Kind and familiar staff
People were cared for by staff who knew their needs and preferences. Inspectors saw staff taking time to listen and communicate with people.
“People were cared for and supported in a kind and compassionate way by staff that knew them well and were familiar with their needs.” from the report
Safe medicines practice
Staff who administered medicines were trained and assessed as competent. Inspectors found correct stock levels and accurate medicines records during a random check.
“We completed a random stock check of medicines and found stock levels correct, staff completed documentation correctly and audited medicines regularly to ensure people were safe.” from the report
Meaningful activities
People could join activities suited to their interests and abilities. Inspectors saw activities including quizzes, pottery painting and knitting.
“There were various activities in different rooms during the inspection. Several residents were engaged in each one and there was pleasant chat and banter.” from the report
Involvement in care
People and relatives were involved in assessments, care planning and reviews. Staff supported people's choices and personal relationships.
“People, and their relatives where appropriate, had been fully involved in the planning and reviews of the care and support provided.” from the report
Conflicting hoist instructions
seriousOne care plan gave different instructions about the sling size and hoops to use. The report says this created a risk that staff might not follow the correct guidance, including guidance relating to the person's head.
“This meant there was a risk that staff would not follow the appropriate guidance whilst using the hoist.” from the report
Care records not fully updated
needs fixingOne person's changing needs had not been recorded correctly. There was also no clear audit trail explaining decisions about changes to the hoisting equipment.
“We found that improvements were still required to ensure care plans were appropriately updated with the correct information and guidance.” from the report
Staff supervision needed improvement
needs fixingStaff received supervision, but it was not happening as consistently as the registered manager wanted.
“However, supervisions were still not where the registered manager wanted them and required improving.” from the report
Early breakfast arrangements
minorSome people who got up early had been waiting for breakfast. The manager said people could have breakfast when they wanted and put up reminders during the inspection.
“If you get up early you have to wait for your breakfast.” from the report
- 01What has been done to make sure every hoist care plan gives one clear and correct instruction?
- 02How are changes to equipment and moving and handling guidance recorded and checked?
- 03How often will staff receive supervision, and how will you monitor that this is happening?
- 04Can people have breakfast when they choose, including if they get up early?
- 05What improvements have been made since the previous inspection, and how are they being checked?
This was an unannounced inspection covering all five areas: Safe, Effective, Caring, Responsive and Well-led; inspectors spoke with 11 people, five relatives and seven staff and reviewed two care plans. This explanation was written from the published report of 9 January 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.
What inspectors found, September 2017
Rated Requires Improvement; inspectors found kind and effective care, but staffing, care records and management checks were not reliable enough.
Inspectors visited unannounced on 16 August 2017. They observed care, spoke with people, relatives, staff and the manager, and reviewed care, medicines, training and management records.
People generally felt safe and were treated kindly. Medicines were managed safely, staff were trained, consent was sought, and people received support with healthcare, activities, meals and personal care.
The home did not always have enough staff available when people needed help. Some people waited for food or assistance, including in an assisted dining area. Care records were not always updated, and management checks did not consistently identify these problems. The overall rating was Requires Improvement. Safe and well-led were Requires Improvement, while effective, caring and responsive were Good.
Safe medicines
Inspectors found that medicines were given as prescribed, recorded correctly and stored safely.
“People had their medicines administered as the prescriber intended.” from the report
Trained staff
Staff received training, supervision and appraisals to support them in providing care.
“Staff received appropriate training and development to provide safe and effective care to people.” from the report
Kind and dignified care
People were treated with kindness, and staff generally protected their privacy and dignity.
“People were supported appropriately by staff who ensured their privacy and dignity was maintained.” from the report
Personalised support
Staff knew people's routines, preferences and backgrounds and used this knowledge in daily care.
“Staff were knowledgeable about people's preferred routines, likes and dislikes, backgrounds and personal circumstances” from the report
Family involvement
Relatives were involved in care planning and could visit at any time of day or night.
“People and relatives told us they were regularly involved in developing and reviewing people's care.” from the report
Staffing delays
needs fixingPeople waited for assistance, food and drinks because staff were busy elsewhere. Staff also said there were not enough people consistently available.
“On the day on inspection however we found that people suffered a delay when requesting staff assistance.” from the report
Food safety risk
seriousA person in an assisted dining area was left unobserved and took food that did not match their assessed diet. Inspectors said this increased the risk of choking.
“They had then managed to take another person's breakfast, which was not the correct consistency as assessed by the dietician.” from the report
Out-of-date care records
needs fixingSome care plans and assessments were not updated when people's needs changed. One person's falls and nutritional records were out of date, and dietary guidance did not match.
“People's care records required improvement to ensure they were updated either when routinely reviewed or when people's needs changed.” from the report
Weak management checks
needs fixingProvider audits did not cover important areas such as staffing, recruitment and risk management. This meant they failed to identify problems found during the inspection.
“The overall monitoring of the service by the provider was not an effective system, and did not identify areas of concern found at this inspection.” from the report
Long gap between meals
needs fixingPeople could go from the evening meal until the next morning without a snack unless they asked for one. Inspectors discussed making snacks easier to access.
“People therefore who were asleep at 8pm were likely to miss out on an evening snack from 5pm through till 9.30am.” from the report
- 01How many staff are on duty now during mornings, meals and other busy periods, and how do you adjust this when people's needs increase?
- 02How do you make sure people in assisted dining areas are observed and receive food at the correct consistency?
- 03How often are care plans, falls assessments, weights and nutrition records updated after a person's needs change?
- 04What checks now cover staffing, recruitment, risk management and care records, and how do you act on problems found?
- 05How are evening snacks offered to people who are asleep or unable to ask for them?
This was an unannounced inspection of the overall service and all five CQC questions, including observations, discussions and reviews of care, medicines and management records. This explanation was written from the published report of 27 September 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.
Every inspection of Willowthorpe Care Home
4 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- January 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2017Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2016Goodup from Requires improvementEffective: GoodWell-led: Good
- March 2016Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 16 December 2010.
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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