Willow House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. This is the first time we have inspected the service since the provider changed. This key question has been rated good.

This meant people were safe and protected from avoidable harm.

This service scored 75 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety. Concerns were raised to the registered manager and these concerns were investigated.

Lessons were learnt to continually identify and embed good practice. Staff analysed audits and changed their ways of working with people. This meant staff were able to improve care for people.

Incidents and accidents were recorded and reviewed by the management team to ensure actions were implemented. We looked at several incidents and found the provider had supported people involved and a lessons learnt exercise had been completed. For example, additional training was provided by the service to help staff support a person when they experienced seizures at night. This ensured staff knew how to keep this person safe.

People and staff knew how to raise concerns outside of the management team. Of the 4 staff we spoke with, all told us what they would do to help prevent the development of a closed culture. For example, if staff witnessed unsafe practices when delivering care, they told us they would raise a concern. Staff knew who to contact in the event of any concerns being identified.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Where possible people were supported to review their own care plans and helped to write their one-page profiles. Where this was not possible, people’s relatives had contributed to these documents. One-page profiles ensure health care staff have a good understanding of a person’s needs to enable continuity of care.

For people who had moved across from a previous provider, care planning documents demonstrated they were put first. For example, the provider had thought about how people would feel and what support they would need to move between providers. Relatives were invited to meet the provider before their family member moved to the service. The provider had reviewed all care planning documents from previous placements to ensure people were receiving care tailored to their individual needs.

The provider worked with people to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

People told us they felt safe in their home and staff helped them stay safe. Staff we spoke with, all informed us they understood what safeguarding meant. Staff talked about examples of how to keep people safe when providing care. One member of staff spoke to us about best practices such as confidentiality and the importance of raising a concern.

Staff received safeguarding training and records demonstrated when they needed to complete refresher training. This meant there was effective oversight of training compliance.

People were supported to stay safe in the community. A person’s risk assessment for accessing the community showed staff had thought in detail about how to keep them safe. There were easy read documents on how to speak up and how to complain if people wished to discuss anything of concern.

Leaders had identified safeguarding concerns and acted promptly by raising concerns to the local authority safeguarding team.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people’s health, safety and welfare had been assessed and action taken to manage those risks. For example, people at risk of falls had a support plan and risk assessment in place. Staff demonstrated a good understanding of the risks and ensured care plans were updated regularly with people when their needs changed. There were detailed and individualised risk assessments for a person who had recently started experiencing seizures at night. Another person had regular mood changes and these were reflected in their risk assessment.

The provider told us they had successfully worked with local stables to support people to access horse riding and animal management activities. One person’s relative told us this enabled them to be more independent. This demonstrated the provider’s commitment to supporting people in an empowering way.

The provider controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider assessed the home for risks and took action to ensure people, staff and visitors remained safe. People had personal emergency evacuation profiles (PEEPs) which detailed hazards in the home and how to safely support people in the event of an emergency.

Fire alarms were tested regularly and people had been involved in a fire evacuation drill. The registered manager assessed the risk of legionella’s disease and ensured testing of the water was completed.

In June 2025 the boiler failed and instant hot water was not available. Leaders took action to ensure their business continuity plan was followed. Alternate arrangements for hot water were sourced. This ensured that risks to people were mitigated, and people still received their regulated activity.

Some areas of the kitchen required maintenance. The registered manager told us there was a plan for a kitchen refurbishment in 2026. This would also mean action was going to be taken to make the kitchen open planned and more accessible to people.

There were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care that met people’s individual needs.

On-call staff were used to cover any staff sickness. This minimised the risk of any shortfalls in staffing and ensured people received support from staff they knew well.

People and their relatives told us there were enough staff to meet their needs, including support for them to attend community-based activities.

Pre-employment checks had been completed for staff before starting work. New staff received an induction, including shadowing experienced staff. Staff told us they received regular training, supervision and an annual appraisal. This ensured a competent and safe workforce when supporting people.

Staff told us there was always someone to talk to if they had any queries out of hours. They said they could enter the office at any time to speak with leaders. Staff told us there were always plenty of well-trained staff to support the service.

The provider assessed and managed the risk of infection and told us they would raise anything with appropriate agencies promptly.

However, a shortfall was identified with the joiners of the kitchen worktop and the chips in the worktop which meant food could be at risk of infection. The registered manager had raised this to the provider.

People told us staff supported them to keep their home clean.

Staff completed infection prevention and control (IPC) training and told us they had access to all the personal protective equipment they needed. We saw IPC audits had been completed. Staff spoke to us about the importance of personal protective equipment (PPE) and told us PPE was available throughout the service.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning their medicines support, including when changes happened.

People told us staff provided good support for them to take their medicines. Staff had completed training in the safe management of medicines and leaders regularly observed their practice. Medicines audits and competency spot checks were completed to ensure staff knew how to dispense and administer medicines safely.

People were supported to have regular reviews of their medicines with their doctor. The provider was working in line with STOMP guidance. This ensured people were not prescribed more medicine than necessary. Medicines errors were documented and raised in the appropriate way. All people had medicine risk assessments, body maps for emollients and guidelines in place. The medicine administration record (MAR) chart showed all medicines including topical creams had been given as required. This ensured people were taking the right medicines at the right time.