Willow Grange Care Home

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 good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 62 (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, and culture. This was based on providing people with the best quality of life and care they could provide, understanding challenges and the needs of people and their communities.

Staff understood the registered manager’s values for the service were to ensure people received the best care they could offer. Staff were complimentary of the registered manager and told us they felt fully supported by them. They reported the registered manager had an open-door policy and they were supportive and approachable. Staff meetings took place and provided staff with the opportunity to have their voices heard.

A member of staff told us, “The service stands for caring for people and fully caring for them. Being always here for the resident. I have learned a lot here, like even if some residents are constantly calling, we are told to respond to them every time even if with a just a few words, some people just want someone to talk with. I would recommend this home because people are eating healthy, getting personal care very well, we are protecting them and their health.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively.

Staff were provided with an induction, training and shadowing opportunities prior to commencing fully on shift. Staff spoke positively of the registered manager and found them to be supportive and approachable. Several staff provided examples of how the registered manager had supported them personally. One member of staff told us, “The manager is very supportive and like a mother to us. She is very free with us but will make sure you do the right thing! Because of the way she is, other staff, for example the seniors, are the same. She supports us very well. Because of how she is when you are working, you work with all your heart.”

There was a staff recognition system in place. The registered manager told us, “We do ‘outstanding employee’ award for staff going above and beyond; we ask staff to make nominations and put them forward. Staff also receive an award when they have been here 5 and 10 years.”

The registered manager reported they were fully supported by the provider, who was also on site during the inspection.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff were aware of the provider’s whistleblowing policy and were confident if they raised concerns they would be listened to. Many of the staff had worked at the service for a number of years. All staff described the working environment ‘like a family’ and were supportive of each other.

Staff’s voice was also sought through staff surveys. One member of staff told us, “If I had any concerns I would raise them, but I ask questions all the time and there have never been any complaints. They are very open.” Another said, “I have done surveys and when you have a meeting, if you have something to tell them [the registered manager] they will quickly take action. They are responsive to requests for help and support.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

A diverse workforce was evident, and additional efforts had been made to support staff employed from overseas.

One member of staff confirmed flexible working arrangements had been put in place to support them, and another advised they had been supported with their further education. A member of staff told us, “I enjoy working here because I am supported and listened to. If I suggest something, for example that is in the best interests of a resident, it is dealt with. I feel valued here and very comfortable, because it is the best for all residents.”

The provider was reactive to concerns raised but not proactive. They did not always act on the best information about risk, performance and outcomes.

The service had received support from local authority commissioners following a serious incident and an action plan was put in place to address the shortfalls identified.

Policies and procedures had been updated to reflect lessons learnt, but some of the changes had not been carried through to daily actions. For example, the provider’s policy stated in the event of a person suffering a serious head injury, ‘basic observations may be done as soon as possible… then every 15 minutes for one hour, one half an hour late...’ There was no system in place to ensure these additional observations were recorded, allowing staff to identify any deterioration the person’s wellbeing. The registered manager took steps during the inspection to ensure a process was put in place.

Policies and procedures had not been robustly reviewed. Updates had been added to policies, but they had not been reviewed as a whole to ensure the necessary information had been removed and what remained, was correct and up-to-date.

A number of audits were in place but not all of them were robust and had not identified the areas for improvement that had been identified during the inspection. The registered manager was reactive to concerns raised, but not proactive. They had taken onboard the guidance and support from the local authority commissioners and were receptive to feedback given during the inspection process and had acted quickly to address the concerns raised during the inspection.

The registered manager had failed to ensure CQC was correctly notified of safeguarding events. Accidents and incidents were investigated. However, the registered manager had failed to ensure interviews with staff following these investigations were robustly recorded.

Audits had failed to identify a number of environmental issues identified during the inspection. For example, a window restrictor on the first floor landing was not fully secure and two items of equipment in a bathroom were worn and rusty and posed an infection control risk.

The registered manager had begun attending a number of manager forums in order to forge links with other managers and share learning.

Staff reported they understood their roles and responsibilities and changes in practice were communicated with them.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

People, relatives and staff told us there was a real sense of family in the home. People’s views of the service were sought through residents’ meetings and surveys. Professional partners were complimentary of the service. Systems were in place to ensure information was shared with other healthcare professionals.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience and did not always actively contribute to safe, effective practice and research.

There was a lack of evidence to demonstrate the service focussed on continuous learning, innovation and improvement. The service was more reactive than proactive. A service users survey had been competed but failed to evidence and record the follow up action that had been taken following the completion of the survey.

There was an action plan in place issued by the local authority and whilst actions had been taken to address the areas of concern identified by the local authority, the provider’s own audits had failed to identify the shortfalls that had been bought to their attention initially by local commissioners and this inspection.

Staff reported they felt well supported by the registered manager. The registered manager and her staff were receptive to all feedback during the inspection process and responded immediately to rectify any areas of concern that were identified.

Staff reported the positive impact of an electronic care recording system that had been introduced. One member of staff was concentrating on learning what the system had to offer and sharing her learning. Another member of staff described the previous system used ‘was poor’ but things were much improved.