Willow Court Nursing Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

Some aspects of the service were not consistently safe, and there was limited assurance that people were protected from avoidable harm.

The service was in breach of legal regulations in relation to safe care and treatment and good governance. Risks to people were not always assessed or managed effectively. Environmental hazards were not consistently addressed, and medicines were not always managed in line with professional standards. The provider had not embedded effective learning from incidents.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not consistently learn lessons or embed them into practice following safety incidents.

For example, a person who had previously experienced a stroke and was at risk of choking, did not have care plans or accurate risk assessments in place. This occurred despite 2 similar incidents earlier in the year involving 2 other people, where 1 person suffered a choking episode and 1 person experienced delay in escalation following a stroke.

Information from previous incidents was not used to improve practice or guidance for staff. This meant actions were not taken to reduce the risk of similar events happening in the future, leaving people exposed to risk of avoidable harm.

The provider responded to specific complaints and concerns with investigations and remedial actions. However, proactive systems to identify, monitor, and address emerging risks were not consistently in place, and a culture of learning from incidents to prevent recurrence had not been fully embedded.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People told us hospital appointments and transfers were well organised. One person said, “My transfer from the hospice to here was very smooth.”

Staff worked well together to support people effectively during transitions. For example, when a person was due to move to another service, staff arranged a phased discharge, allowing the person extra time before moving while maintaining close communication with the other service to ensure continuity.

Staff supported people to attend hospital appointments and share relevant information with the hospital team. This helped reduce people’s anxiety, supported continuity of care and maintain positive health outcomes.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

The provider shared concerns quickly and appropriately and people told us they felt safe.

Safeguarding policies, procedures, and training were in place, and staff understood different types of abuse, including physical, emotional, and financial. Records confirmed that safeguarding concerns were raised with external agencies, investigated, and outcomes documented. Actions taken to protect people were clear and proportionate.

One senior staff member told us, “I will always report safeguarding concerns to my line manager. I would also tell the designated safeguarding lead and inform local authorities if needed”. Another staff member said, “If abuse is suspected or occurred, I would report to the management or directly to social services and CQC”.

Staff told us that supervision and operational checks reinforced staff responsibilities and supported the consistent application of safeguarding knowledge in practice. Whilst some staff told us they did not always feel able to raise general concerns regarding conflict amongst staff or workload pressures, reflecting a wider culture of fear of reprisal in parts of the service, this did not affect the safe management of safeguarding issues.

The service did not assess or manage risks to people’s safety. Staff worked without clear guidance, and people were exposed to avoidable risk of harm.

A person living with Chronic obstructive pulmonary disease (COPD) and using oxygen had no risk assessment for breathing difficulties, and staff had no clear guidance on how to recognise or respond to respiratory deterioration. Their emollient risk assessment was generic and did not consider the specific fire risk of using oily emollients near oxygen, in line with the Health, Safety and Environment (HSE) guidance.

Another person’s bed rail risk assessment was not reviewed within the provider’s required timeframe. It relied on yes and no answers, and did not consider entrapment risks, the person’s behaviour, their views, the need for bumpers, or less restrictive options. A more detailed general assessment existed, but it did not reflect the individual level of risk.

Risk assessments for a person at high risk of choking were also unsafe. Daily notes showed repeated concerns, including food pocketing, the person’s mouth being full of old food, and staff removing dentures to reduce choking risk. Despite this, both the choking and oral health risk assessments scored the person as no risk, and the care plan had very limited information in place to guide staff in the event of a choking episode.

The provider acknowledged these failings during the inspection and reviewed, updated or created the relevant risk assessments and care plans.

The provider did not always detect and control potential risks in the care environment. Unsafe equipment, storage practices and gaps in environmental safety placed people at avoidable risk of harm.

We found several hazards in the care environment that the provider had not identified or addressed before inspection. Wardrobes in people’s bedrooms were unsecured, creating a risk of tipping or crush injuries. Oxygen cylinders were not stored safely, with some placed near combustible materials, in escape routes, and 1 used to prop open a door.

We also identified concerns about the security of the outdoor area. A person assessed as being at high risk of absconding had accessed the garden and climbed over the gate. Incident records reviewed did not contain sufficient detail to clearly evidence the level of staff supervision at the time of these incidents. Environmental risks included a low section of perimeter fencing, a 6–10-foot drop on the external side of the fence, and an emergency release button on one gate that could allow an unsupervised exit. The garden risk assessment focused mainly on restricting access and did not fully address the physical hazards present in the outdoor area.

The provider responded positively when we raised these concerns. They secured wardrobes during the inspection, relocated oxygen cylinders to comply with safe storage requirements, and acknowledged the shortcomings in the garden risk assessment. They told us they had already identified issues with the perimeter fencing and confirmed they were exploring increasing the fence height to 1.8 metres to reduce the risk of unauthorised exit and falls.

The provider did not always ensure there were enough qualified, skilled, and experienced staff to meet people’s needs effectively.

The service assessed each person’s dependency individually, but it did not have an effective system to calculate the combined care needs of all people. There was no process to link individual dependency scores to the staff hours required or to use this information to check whether staffing levels were sufficient. As a result, the provider could not be assured staff allocations consistently matched the total care needs of everyone living in the service.

Staff reported feeling short-staffed on some days, which increased pressure and affected the time they could spend with people. One person said, “The care is very good, but I feel it’s understaffed at times. They have so much to do.” Another person observed, “They always seem to be rushing around and so busy.”

Despite these shortfalls, the provider had robust recruitment and training processes. Recruitment files met Schedule 3 requirements, including references, right-to-work checks, and Disclosure and Barring Service (DBS) clearance. Agency staff records included the same safeguards. This ensured staff were properly checked and trained, but the service needed to strengthen staffing oversight to make sure enough staff were available at all times to meet people’s care needs safely. The provider took immediate action to address shortfalls identified during our inspection and began reviewing the staff needed to meet people’s needs and allocation process.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The home was visibly clean and well maintained, reflecting a high standard of hygiene throughout the service. People spoke positively about cleanliness and how staff maintained the environment. One person said, “They clean my room every day and sort out all my washing,” and another explained, “They keep the place clean and tidy and always do what you ask.” A relative added, “The place itself is nice, clean and welcoming.”

The management team carried out staff’s IPC spot checks, to ensure adherence to policy and safe practice. The provider encouraged staff to receive seasonal vaccinations, including the flu vaccine, and people using the service were supported to access available vaccinations.

Staff followed infection prevention and control (IPC) policies, including robust COVID-19 risk assessments and an up-to-date annual IPC statement. Staff completed daily and deep cleaning schedules were completed, and monthly audits were carried out with recorded action plans and outcomes.

Regular monitoring and structured audits ensured any potential risks were promptly identified and addressed, minimising the risk of infection.

The provider did not always make sure medicines were managed safely or in line with people’s needs, preferences, and the service’s own policies. Record-keeping and systems for oversight were inconsistent, increasing the risk of errors.

PRN (as-needed) medicines were generally given without clear rationale and were not consistently documented, meaning staff could not always demonstrate why medicines had been administered. Topical medicines were stored in people’s rooms without an individual risk assessment, Medication administration records (MAR) instructions were sometimes vague, and body maps were missing.

Records for blood glucose monitoring, insulin administration, allergy status, and storage temperatures were not always clear or consistently recorded. Daily stock checks were not always carried out, reducing accountability. These issues did not cause immediate harm but increased the risk of medication errors.

A review of multiple people’s records showed recurring trends, particularly around PRN use, topical medicine management, and inconsistent stock checks, indicating systemic weaknesses not identified by audits.

During the inspection, the provider took action to address the issues identified. MAR charts were reviewed, PRN protocols clarified, topical medicine storage risks addressed, and auditing processes strengthened. Plans were confirmed to improve medicines governance, monitoring, and record-keeping to reduce risk and ensure medicines are managed safely across the service.