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CQC report explained · a nursing home, run by St. Matthews

Willow Brook House

77 South Road, Corby, NN17 1XD

Requires improvementpublished 17 February 2024, 2 years ago

Rated Requires improvement: inspectors found the service was not performing as well as it should and told it what to change.

The five questions inspectors ask
Safe?
Requires improvement
Risks had been identified and plans were in place, but staff did not always know or follow the required measures. PRN medicine protocols also did not always explain clearly when medicines should be given.
Effective?
Requires improvement
Staffing, training, health appointments, nutrition monitoring and consent arrangements had improved. However, a clinical handover document was still being developed, so changes in people's health might not be easily identified.
Caring?
Good
People were treated with kindness, dignity and respect. They were involved in care decisions and could choose how to spend their time.
Responsive?
Requires improvement
Activities and complaint handling had improved, and people were supported to maintain relationships. Care plans were still basic, and staff needed better guidance to support people with enhanced needs.
Well-led?
Requires improvement
Additional managers and monitoring systems had been introduced, and people and staff felt listened to. The systems were not yet fully embedded, and the inspection could not fully assess their effect because there had been no new admissions and only 17 of 43 places were occupied.
The latest report, explained

What inspectors found, February 2024

Willow Brook House is rated Requires Improvement; inspectors found kind care and better staffing, but important safety, care planning and management systems still need work.

The inspection was unannounced and took place on 9 and 10 January 2024. One inspector, a specialist nurse adviser and an Expert by Experience spoke with people, relatives and staff. They also checked care records, medicines records, recruitment files and management records.

The home had improved since its previous Inadequate rating. Staffing, medicines, safeguarding, complaints and consent arrangements had improved. People said staff were kind, respectful and responsive, and the caring rating rose to Good.

However, the overall rating remains Requires Improvement. Staff did not always follow risk plans, some medicines instructions were incomplete, care plans were basic, and a new nursing handover system was not yet in place. The systems used to monitor quality and safety also needed to be embedded and sustained.

What inspectors praised

  • Kind and respectful care

    People and relatives described staff as kind and respectful. Inspectors saw staff using calm, positive language and protecting people's privacy.

    “People received kind and compassionate care from staff who used positive, respectful language which people understood and responded well to.” from the report

  • Improved staffing

    The home had recruited permanent staff and was no longer relying on agency staff. Inspectors found enough staff during the visit, including one-to-one support where needed.

    “The provider ensured there were sufficient numbers of suitable staff. We saw there was sufficient staff to meet the needs of the people during the inspection.” from the report

  • Safer medicines arrangements

    Medicines were received, stored, administered and disposed of safely. Staff had medicine training and their competence was checked.

    “Safe protocols for the receipt, storage, administration and disposal of medicines were followed.” from the report

  • More activities and improved complaints handling

    People had access to exercise, karaoke, walks and other activities. Complaints were recorded, investigated and shared with staff.

    “Since the last inspection the registered manager had ensured people had more access to a variety of activities.” from the report
What inspectors were concerned about

  • Risk plans were not always followed

    serious

    Staff did not always understand or apply the measures in people's risk plans. Inspectors gave an example of prescribed anti-embolic socks not being worn.

    “Risks to people's care had been identified but the measures in place to mitigate those risks were not always consistently applied.” from the report

  • Incomplete medicine instructions

    needs fixing

    Some PRN medicine protocols did not explain clearly how a person might appear when they needed the medicine. This could make it harder for staff to know when to give it.

    “PRN protocols provide staff with sufficient information to guide them as to when to administer the prescribed medicine.” from the report

  • Health handover not yet in place

    needs fixing

    A clinical handover document was being developed but had not been implemented. The inspectors could not yet assess whether it would help nursing staff notice deterioration quickly.

    “At the time of the inspection this had not yet been implemented.” from the report

  • Basic care plans and limited activity guidance

    needs fixing

    Care plans did not give a detailed enough picture of people's preferences and needs. Staff also needed more guidance about suitable activities for a person receiving enhanced support.

    “Care plans were basic and included people's preferences, likes and dislikes, spiritual and communication needs.” from the report

  • Quality checks needed strengthening

    needs fixing

    Management checks and records did not always show whether actions had been completed. Some checks focused on the building and did not include people's clinical needs.

    “The systems in place to monitor the quality and safety of the service needed to be improved, embedded and sustained to be able to fully assessed.” from the report

  • End-of-life plans were limited

    minor

    Some advance care plans contained only basic information about people's wishes, spiritual needs and resuscitation decisions. No one was receiving end-of-life care during the inspection.

    “The information was limited and included people's basic wishes as to where they may wish to be at the end of life, their spiritual needs and cardiopulmonary resuscitation (DNACPR) decisions.” from the report
Questions to ask them, based on this report
  1. 01How do you check that staff understand and follow each person's risk plan, including instructions such as wearing anti-embolic socks?
  2. 02What has been changed in the PRN medicine protocols, and how do staff decide when a person needs an as-required medicine?
  3. 03Has the clinical nursing handover document now been introduced, and how do you identify a change or deterioration in someone's health?
  4. 04How are care plans being made more detailed and person-centred, particularly for people needing enhanced one-to-one support?
  5. 05What evidence shows that management checks are completed and that actions from meetings and audits are followed through?

This was an unannounced follow-up inspection covering all five key questions after the previous Inadequate rating; the impact of recent management changes could not be fully assessed because there had been no new admissions and only 17 of 43 places were occupied. This explanation was written from the published report of 17 February 2024 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 Willow Brook House

2 rated inspections over a year: the service has improved, from Inadequate to Requires improvement.

  1. February 2024Requires improvementcurrent ratingup from Inadequate
    Safe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement

    Read what inspectors found at Willow Brook House →

  2. August 2023Inadequate
    Safe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate

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

  3. July 2022

    Registered with the Care Quality Commission on 21 July 2022.

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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