Willow Home Care Ltd

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 inadequate. At this assessment the rating has remained inadequate.

This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment and the management of people’s medicines.
 

This service scored 31 (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. Lessons were not learnt to continually identify and embed good practice.

The provider failed to ensure all incidents and accidents were thoroughly investigated and used as opportunities for learning and improvement. Where incidents were investigated and actions were identified, these were not consistently completed. Following an incident involving equipment, the reviewing manager had concluded there was no evidence of equipment failure, despite the incident record stating staff had not noticed the equipment was becoming unsuitable for the person. There was no evidence of an investigation into the suitability of the equipment or how the incident occurred. Although the staff involved were required to repeat moving and handling training, records showed one staff member had left and the other had not completed the training. Therefore, the provider could not demonstrate learning had been embedded, or action had been taken to reduce the risk of recurrence and promote safety.

The provider failed to ensure all incident records contained evidence of any management oversight or review. While staff completed incident forms, these were not consistently reviewed by a manager to assess how the incident had been dealt with. This failure meant potential risks to people and staff may not have been identified, and opportunities to learn, improve practice, and promote safety were missed.
 

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

Although the provider had systems in place these were not managed well. When people were discharged from hospital into the provider’s care, the registered manager told us a photograph of their discharge summary along with their prescribed medicines was taken by staff at the first care call. This was then sent to the office staff so they could update care records as necessary. However, we found multiple examples where this process had not been followed, such as when 1 person had been discharged from hospital, and it was not until 21 days later it was identified one of their medicines had changed. This showed the provider’s own processes were not followed.

People’s care plans, risk assessments and medicine information were not always kept up to date. We also found significant spelling errors relating to people’s medical conditions which could impact on staff's understanding of their care. This increased the risk of staff and healthcare professionals misinterpreting important information, potentially affecting the safe and effective delivery of care.
 

People did not always feel safe and reassured by the service they received from Willow Home Care Ltd. Not everyone was supported by a consistent staff team and were not told if staff would be late or if there were changes to their expected staff. People told us they did not always feel safe when new or different staff arrived as they did not know them. One person told us they felt uncomfortable not knowing which staff were coming to their home, they said, “I do not know who is coming and I don’t know the time (they are coming).”

People were not consistently safeguarded against known risks. The provider had not ensured people were protected from unsafe staff practice. Staff had repeatedly hoisted 1 person and left them suspended in the hoist for periods of time, placing them at risk of avoidable harm. Staff had not recognised this as unsafe practice. We also found staff were carrying out a task for another person without the appropriate training or authorisation. The provider had not identified either concern, despite both being recorded in people’s daily records. This demonstrated ineffective oversight and a failure to recognise and respond to safeguarding risks. Following our assessment, we made 2 safeguarding referrals to the local safeguarding authority.

We viewed a safeguarding concern which the provider had raised with the local safeguarding authority. Although this had been discussed with the local safeguarding authority, there was no record of actions taken by the provider to keep the person safe.

The provider had a safeguarding policy in place. However, the policy had no internal process for the registered provider to safeguard people or investigate any concerns. This had originally been identified by CQC in February 2026 during a registration update. At this assessment we found the policy had not been updated as we had advised. This was updated following our assessment.

Staff had received training in safeguarding people and understood how to report concerns. Although the registered manager was the organisation’s safeguarding lead, there was no recorded evidence of safeguarding lead training on the provider’s training matrix. This reduced assurance they had the necessary training and competency to effectively fulfil the role.

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.

Although people’s risks were assessed, the associated records were not always kept updated and did not give clear instruction for staff to support people safely. This had been identified at our previous assessment. One person’s care plan stated they were, “prone to having falls.” But there was no information about why they were prone to falls or what their fall history was. Another person’s care plan stated they were waiting for a hoist so staff could move them safely. However, the person’s care records clearly showed staff had already begun to use a hoist. Despite this change in practice, the person’s care plan and risk assessments had not been reviewed or updated to provide staff with clear, current guidance on how to safely support the person. We also found staff had been told to stop using the hoist with this person, but their care records had not been updated and staff continued to use the hoist. This had put the person at significant risk of harm.

Risk assessments were completed when people first started using the service to identify known risks for that person. However, these were often scored incorrectly and so did not always give a clear, accurate and current picture of people’s safety. One person’s mobility and balance risk had been scored as low risk; however, when accurately scored, this should have been identified as a medium risk. This incorrect scoring meant the person’s care planning may not have reflected their actual needs, which put them at risk of receiving inappropriate or unsafe support.
 

The provider did not always detect and control potential risks in the care environment.

People received their care in their own homes. Although the provider was not responsible for servicing any equipment used, such as hoists, they did need to monitor it was being serviced and for general wear and tear to ensure it was safe for people and staff to use. The provider did not have an established process to support this. However, one of the care coordinators was independently checking the service dates of equipment for their own reassurance. There was no formal system in place to record these checks; however, this was introduced by the second day of the assessment.

The provider completed assessments which looked at people's home environment and identified any fire safety measures in place, access arrangements and how the person could get out of the building in an emergency.
 

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The provider’s training matrix did not evidence any updated or refresher training for staff and only reflected training completed at the start of their employment. One staff member had been employed since 2016, but the training matrix did not evidence any training since then. However, staff told us they attended training often, but not all could tell us what training they had completed. One staff member told us they had attended moving and handling training this year (2026). When we checked the training matrix it stated they last had completed this training in 2024 when they were first employed. This raised concerns regarding the maintenance of staff competency and the effectiveness of ongoing training oversight.

Staff gave us differing feedback about the support they received to deliver safe care. Some told us they did not receive spot checks or supervisions often, whilst others told us they had these regularly. The registered manager told us staff received a spot check of their practice and supervision every 4 months. However, they could not provide any evidence of oversight at the time of assessment, so we could not verify how frequently spot checks and supervisions had been completed for each staff member. They told us, “The end game is to have spreadsheet with all spot checks on.”

The provider’s recruitment and induction practices had improved since the previous assessment. Staff now underwent safer recruitment checks and a structured induction, including shadowing experienced staff before working independently. However, right-to-work records for 2 staff members were dated 1 and 2 months after their employment start dates. The registered manager told us these checks had been completed before employment but were not filed due to printer issues; however, no evidence was available to verify this. We also found interview records missing from several staff files. The registered manager told us these remained with the recruitment agency despite the staff already being employed. This meant the provider could not demonstrate all recruitment processes had been completed before staff commenced employment.
 

People and relatives gave positive feedback about staff hygiene practices. People told us staff used appropriate personal protective equipment (PPE) such as gloves and aprons and disposed of these safely after use. We did receive some negative feedback from some people who told us staff did not always complete cleaning tasks which were part of their care call and did not always throw away out of date food.

The risk of infection had been assessed where people had catheters in place and staff were given instruction to follow strict IPC measures. However, we found the infection risk associated with catheter care were scored inconsistently across three risk assessments despite the same risk factors being identified. This indicated infection prevention and control risks were not assessed in a consistent manner, which reduced assurance people were protected from the risk of catheter-associated infections.

Staff completed infection, prevention and control (IPC) training at their induction training, but the provider’s training matrix showed this had not been updated. This limited assurance that training records were being effectively maintained.
 

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

We found significant shortfalls in the provider’s management of people’s medicines. People’s care plans, daily records and medicine records did not consistently and accurately reflect all prescribed medicines. Information about the medicines people were prescribed were not always up to date and did not always match with their other care records.

The provider had not ensured the administration instructions for medicines were always provided to staff. Some medicines had specific administration instructions and failure to follow these instructions could affect the effectiveness of the medicines. One medicine should always be administered at least 30 minutes before food or other medicines, but staff did not have these instructions. Therefore, the provider could not be assured people received their medicines as prescribed.

People’s topical medicines were not managed safely. Medicine records did not clearly state the reason for prescribed creams or where they should be applied.

People’s care records showed they often ran out of medicines. People’s care plans did not state who had responsibility for monitoring and re-ordering medicine supplies and staff had not escalated low stock or no stock to senior staff.

The provider had not ensured staff followed their own medicine policies. When people needed their “as required” medicine, such as pain relief, the provider’s policy stated staff were to record the outcome or effectiveness of those medicines. However, staff did not record this so the provider could not be assured people’s “as required” medicines were treating the condition they were prescribed for.