Willowcroft Care 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.

The provider was in breach of the legal regulation relating to safe care and treatment.

This service scored 47 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Records we viewed did not consistently show there was a proactive learning culture regarding health and safety incidents or concerns, and that these had not been effectively reflected upon and used to drive improvement.

Incidents were recorded and an analysis created, however they did not clearly detail what action had been taken in order to monitor the effectiveness of changes. We asked the provider to take action on the shortfalls found, which they started to action immediately.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Where information had been recorded and updated in people’s care plans, it had not always been transferred effectively into the overall summary. This placed people at risk of receiving care that was not fully informed and posed a risk of incorrect information being shared with external healthcare professionals. This was raised with the provider who told us they would review all care plans to ensure they were up to date and relevant.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

There was a record of safeguarding incidents which showed action had been taken, however this did not provide information on what lessons had been learnt in order to minimise the incidents happening again.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service and found where needed people had DoLS authorisations in place. However, we found MCA assessments were not always completed or lacked evidence on how the conclusion to the assessment had been drawn. They did not follow the key principles of the Act to make best interests decisions.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Assessments and care plans were in place, but some lacked clear guidance for staff, including escalation pathways for changes in people’s health. Care plans also contained contradictory or incorrect information which placed people at risk of receiving inappropriate care. For example, a person who required support with their mobility needs had inaccurate information in their care plan.

Not all people had risk assessments in place associated with their care and support needs, or environment. This placed people at risk of harm and unlawful deprivations of their liberty. For example, we found a restriction across the home for people to have alarms on their room doors. Consent, capacity assessments or risk assessments had not been completed. People who had capacity told us they had not been given a choice if the alarms were on their bedroom doors, nor had it been explained to them why they were there.

The provider told us they took action following our assessment to make improvements to door sensors used in the home.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Assessments and care plans were in place, but some lacked clear guidance for staff, including escalation pathways for changes in people’s health. Care plans also contained contradictory or incorrect information which placed people at risk of receiving inappropriate care. For example, a person who required support with their mobility needs had inaccurate information in their care plan.

Not all people had risk assessments in place associated with their care and support needs, or environment. This placed people at risk of harm and unlawful deprivations of their liberty. For example, we found a restriction across the home for people to have alarms on their room doors. Consent, capacity assessments or risk assessments had not been completed. People who had capacity told us they had not been given a choice if the alarms were on their bedroom doors, nor had it been explained to them why they were there.

The provider told us they took action following our assessment to make improvements to door sensors used in the home.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

We found many large heavy wardrobes to be unsecured from walls in people’s bedrooms. This meant large heavy wardrobes could tip or fall, which increased the risk of harm to people. We found topical creams and razors in people’s bedrooms which had not been stored safely to minimise the risk of harm. We raised this with the provider who took immediate action.

We found cables and wires were on people’s beds and loose wires were near people’s pillows which posed a risk of harm. These concerns had not been identified by the provider on their environmental checks.

The provider was receptive to our feedback and acted upon the concerns raised. They acknowledged the improvements required and demonstrated a commitment to people to improve the safety of the service.

The provider did not always make sure there were enough qualified, skilled and experienced staff.

At the time of the assessment there were insufficient staff on duty to ensure people received timely care and support to ensure their safety was maintained.

Staff working at Willowcroft Care Home knew people who lived at the service well. However, throughout the assessment, people were left without stimulation. The provider had one full-time activities coordinator and another parttime activities coordinator however, they could not support on all floors within the home. There were not enough care staff to provide social stimulations, due to responding to people’s personal care and emotional needs.

There were periods in the day where people required more emotional support, however due to staffing levels, these needs were not always met. This was raised with the provider who told us they were adequately staffed according to people’s needs. The provider did take action and reviewed staffing levels. Evidence on how they had calculated the required increase was not provided and therefore we were not fully assured staffing had been safely addressed.

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.

Staff had completed infection prevention and control training. Staff knew what personal protective equipment they should wear and when. Staff knew how to put on and remove this equipment in a safe way. This protected people from the spread of infection.

The kitchen was clean and well maintained. Since our last visit the food standards agency had completed a visit and had rated the service 5 on the 28 May 2025 meaning hygiene standards were very good.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

The provider had a clinic room where medicine trolleys were stored. This was clean, tidy and well organised. Generally, stock levels were adequately managed. However, on reviewing medicine administration, we found instances where people had missed multiple doses of pain relief due to this not being in stock. This meant that people were at risk of being in pain due to poor medicines management.

We found some instances of missed signatures in the controlled drugs book, and the same for disposed of medicines. These should have 2 signatures, however there were instances where there was only one signature.

We found topical creams in people bedrooms which were not safely stored.

We observed medicines being administered and found a number of distractions during this time. This increased the risk of medicines errors and therefore placed people at risk of harm.

Staff who administered medicines had received medicines training and were able to explain why people were prescribed certain medicines and what they were for.