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CQC report explained · a residential care home, run by Hatzfeld Care

Willis Lodge Care Home

St. Thomas' Avenue, Kirkby-in-ashfield, Nottingham, NG17 7DX

Goodpublished 13 July 2023, 3 years ago

Rated Good: inspectors found the service performing well and meeting their expectations.

The five questions inspectors ask
Safe?
Good
People felt safe, medicines were administered safely, there were enough staff and incidents were reviewed. Inspectors found delays in updating care records after choking incidents and incomplete legionella follow-up at the time of inspection.
Effective?
Good
People had detailed assessments, trained staff, support with food and access to health and social care professionals. The home supported people to make choices and live more independently where appropriate.
Caring?
Good
Staff were observed to be patient, calm, kind and respectful. People were involved in decisions, their privacy was respected and their independence was encouraged.
Responsive?
Good
The ratings table says Good, but the detailed section says the rating changed to Requires Improvement. Inspectors found personalised care, communication support, activities and appropriate complaint handling, but not all end of life plans were in place.
Well-led?
Good
The ratings table says Good, but the detailed section says Requires Improvement. Inspectors found a positive culture and approachable managers, but quality checks had not always identified delayed care record updates or incomplete safety actions.
The latest report, explained

What inspectors found, July 2023

Rated Good overall; inspectors found kind, safe care, but records and quality checks were not always updated promptly.

This was an unannounced inspection on 18 and 24 May 2023. Two inspectors and an expert by experience spoke with five people and eight staff. They reviewed care records, medicines records, staff files and management records.

People said they felt safe and received kind, respectful care. Inspectors found enough staff, safe medicines practice, suitable training, good access to health professionals and support for people to make choices and become more independent.

There were shortfalls. Care records were not always updated promptly after risks changed, and some follow-up action after a legionella inspection had not been completed at the time. The report says these actions were later completed and the impact on people was minimal.

The overall rating is Good. However, the ratings table lists all five areas as Good, while the detailed sections for Responsive and Well-led say Requires Improvement. This inconsistency should be clarified with the home.

What inspectors praised

  • Kind and respectful staff

    People described staff as kind and caring. Inspectors saw staff remain calm and patient, including when people became upset or agitated.

    “People told us staff were kind and caring and they liked their company.” from the report

  • Safe medicines practice

    Medicines records were accurate, medicines were stored and given safely, and staff competency was checked regularly.

    “We noted people's medicine administration records were now completed correctly and accurately reflected people's medicine requirements.” from the report

  • Support for independence

    People were encouraged to prepare food, take part in activities and work towards living more independently.

    “People were encouraged to do things for themselves.” from the report

  • Activities and social life

    People were supported to exercise, go out, meet others and maintain relationships with friends and family.

    “Another person praised the activities and liked the trips out of the home.” from the report
What inspectors were concerned about

  • Care records were not updated promptly

    serious

    After two choking incidents, staff were given new instructions, but the person's care records were still not updated two months after the first incident. This created a risk of inconsistent care.

    “two months after the first incident, the person's care records had not been updated to reflect the action staff should take.” from the report

  • Legionella actions were incomplete

    needs fixing

    Some actions following a legionella inspection had not been completed and there was no action plan at the time. The report says the home later confirmed that these actions were complete.

    “some follow-up action actions had been completed; however, others had not.” from the report

  • Quality checks did not identify all shortfalls

    needs fixing

    The home's governance systems had not picked up the delayed care record updates or incomplete health and safety actions. Managers said responsibilities would be delegated to allow more detailed checks.

    “further checks were needed to ensure care records were amended and actions following health and safety checks were completed in a more timely manner.” from the report

  • End of life plans

    minor

    Not everyone had an end of life support plan. The home said discussing this was not always suitable because it could cause anxiety or upset.

    “Not all people had an end of life support plan in place.” from the report
Questions to ask them, based on this report
  1. 01How do you make sure care records are updated immediately when someone's risks or support needs change?
  2. 02What evidence can you show that all actions from the legionella inspection have been completed?
  3. 03Who now checks the quality of care records and health and safety actions, and how often are these checks carried out?
  4. 04How do you decide when it is appropriate to discuss and record end of life wishes?
  5. 05Why does the ratings table say Good for Responsive and Well-led when the detailed sections say Requires Improvement?

This was an unannounced inspection covering all five key questions, but the report contains conflicting ratings for Responsive and Well-led. This explanation was written from the published report of 13 July 2023 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.

The story over the years

Every inspection of Willis Lodge Care Home

2 rated inspections over 4 years: the service has improved, from Requires improvement to Good.

  1. July 2023Goodcurrent rating
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read what inspectors found at Willis Lodge Care Home →

  2. February 2022Inspected but not rated
    Safe: Inspected but not rated

    We are reading this report · the original is on cqc.org.uk

  3. November 2019Requires improvement
    Safe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement

    Read this report on cqc.org.uk

  4. October 2018

    Registered with the Care Quality Commission on 11 October 2018.

Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.

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