Willow Tree Lodge

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question as good. At this assessment the rating has remained as good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Although the provider had governance systems in place, they did not always provide effective assurance about the quality and accuracy of records. Care plans and risk assessments did not consistently provide clear guidance for staff, medicines records and ‘when required’ protocols contained inconsistencies, and records did not always demonstrate that people’s outcomes were effectively monitored. Some mental capacity assessments were not decision-specific or sufficiently detailed, and assessments were not evident for some restrictive practices. Audits and governance processes had identified areas for improvement, and steps were being taken to address these areas. These processes had not identified the full detail or extent of the shortfalls, and the actions taken had not yet resulted in sustained improvements. There was no evidence of significant impact on people. Staff had a good understanding of people’s individual needs, supported them safely and promoted their choice and control. The governance shortfalls reduced assurance that safe, consistent and person-centred practice would be sustained.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.