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We are carrying out a review of quality at Willow Lodge. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating


Updated 14 April 2021

About the service

Willow Lodge is a care home providing accommodation and personal care for up to 22 people aged 65 and over. There were 17 people living at the service at the time of the inspection. Some of the people lived with dementia and required support with their physical needs.

People’s experience of using this service and what we found

People told us they felt safe and staff were kind and caring. However, our observations showed that people did not always receive safe care and treatment. Staff had not reported safeguarding concerns to safeguarding authorities including unexplained injuries. People’s care was not delivered in a safe environment which had been maintained to acceptable standards. People’s bedrooms, communal toilets and ensuites did not have call bells for summon help in the event of an emergency. People’s bedrooms did not have additional bedside lighting and lifting equipment had not been inspected and maintained as per manufacturer’s recommendation.

People were exposed to risk of the spread of infections due to poor infection prevention practices and poor hygiene standards around the service. People’s safety had been compromised due to the lack of robust positive behaviour risk management processes. Risks to people were not adequately assessed and reviewed to identify ways to reduce deterioration. People were not always supported with their medicines in a safe manner.

We have made a recommendation about the need to improve the environment to promote independence and good outcomes for people who live with dementia.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. People told us staff sought their preferences, however, staff had made some blanket decisions on people’s ability to make specific decisions without assessing their capacity to make their own decisions. The registered provider had not followed national guidance and best practice to support the effective delivery of care. People were not always supported by staff who had the right competences, induction and supervision to meet their needs. Staff supported people to have access to health professionals and specialist support.

The governance and quality checks did not promote the delivery of safe care and treatment. Environmental and governance concerns from our last inspection in 2019 had not been addressed. The provider had not established good governance in line with best practice to improve the care delivered and to ensure compliance with regulations. The provider had not established robust oversight to support staff on the running of the service and compliance with regulations and to monitor people’s experiences.

For more details, please see the full report which is on the CQC website at

Rating at last inspection and update

The last rating for this service was requires improvement (published 15 May 2019) and there were multiple breaches of regulation. We issued a warning notice for the safety of the environment and asked the provider to be compliant by November 2020. The provider also completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found little in the way of improvements to the environment and the provider remained in breach of regulations associated with people’s safety, medicines, good governance and maintenance of the premises.

Why we inspected

We received concerns in relation to the management of behaviours that can challenge others and safeguarding concerns. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only. This inspection was also carried out to follow up on action we told the provider to take at the last inspection.

We reviewed the information we held about the service. No are

Inspection areas



Updated 14 April 2021

The service was not safe.

Details are in our safe findings below.



Updated 14 April 2021

The service was not effective.

Details are in our effective findings below.


Requires improvement

Updated 14 April 2021


Requires improvement

Updated 14 April 2021



Updated 14 April 2021

The service was not well-led.

Details are in our well-Led findings below.