Willow House

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.

This is the first time we have inspected the service since the provider changed. This key question has been rated 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.

Leaders, managers and staff understood the challenges and the needs of people and their communities and it was evident staff were demonstrating person-centred practice. Staff displayed transparency, equity, equality, human rights, diversity, inclusion and engagement.

The provider had a vision, strategy and culture and this was cascaded to staff. Staff we spoke with were able to identify and talk about the organisation’s values.

Right Support, Right Care, Right Culture was evident in the ways that staff worked with people, and the registered manager embedded this within staff culture. Staff and leaders we spoke to were confident of the regulations they were required to work toward. For example, the provider ensured there was specialist training in place aimed atimproving the care and support provided to autistic people and people with a learning disability. This meant staff had an awareness of the most up to date guidance when supporting people with learning disabilities and autism.

Feedback we received from both staff and relatives showed that leaders were compassionate and inclusive. Staff were happy in their job. Comments included “I enjoy it very much, and the organisation is good to progress within” and [staff are] “caring and interactive, [my relative] has a particularly good key worker who goes above and beyond”.

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. They did so with integrity, openness and honesty.

The registered manager had an open and honest approach to our findings and feedback and was committed to making immediate changes. This included ensuring people had capacity documents, and organising staff training from a clinician.

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

The provider had a whistleblowing policy which had been reviewed, and staff knew how to raise concerns.

Staff told us they were confident if they raised a concern the registered manager would take the appropriate action. Staff felt the registered manager was approachable and supportive.

Relatives told us they were informed of how to raise a concern when they first started using the service and a copy of the complaint procedure was placed in their family member’s support plan. There were systems to enable people to give their views about the service they received. There was an up to date speaking up policy, easy read documentation and people were encouraged to feedback on their care and support. Where this was not possible, relatives were invited to feedback. Records showed any shortfall was properly investigated, with lessons learnt to minimise a reoccurrence.

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.

The provider had supported staff to make reasonable adjustments to their working patterns where needed, to support them in their work. One member of staff told us “My manager gives me shifts that work for me, I do not drive so my shifts are usually together”. Staff told us they felt well supported by the leadership team.

Staff told us they were treated as individuals by the provider. They felt listened to and encouraged to speak up in team meetings and share ideas.

Staff had the opportunity to record information in a variety of ways. This included hand-written, by way of a tablet or on a large computer. This meant staff could access the resources they required to undertake their role.

Staff informed us the provider had put reasonable adjustments in place for them when using public transport to get to and from their place of work.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. However, they did not always act on the best information about risk, performance and outcomes.

There were some areas of governance which required further development. For example, clear recording of consent, recognition of delegated nursing tasks and submission of timely notifications. The provider acted immediately during the inspection to rectify these issues.

Leaders completed a range of audits and observations of staff practice to monitor the quality of the service. This information was used to plan improvements to the service. At the time of the inspection, the provider told us they were looking at introducing new systems to support staff.

The registered manager told us safeguarding case studies would form permanent agenda items on all future team meetings in order to improve staff knowledge and use real examples so that they could deliver safe care. Further, team meeting agendas always had a particular topic that the registered manager discussed with staff. For example, right support, right care, right culture was discussed with staff as a learning exercise. This meant any risks of closed cultures were mitigated.

The provider was transferring care records over to a new digital care system. Staff had an app on their mobile phone which alerted them to any policy changes. This ensured staff were working to the most up to date practice.

There were regular spot checks of staff’s performance and records showed the registered manager had oversight of any accidents, incidents or near miss events. There were formal processes such as staff recruitment, induction and supervisions and a range of up-to-date policies and procedures.

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. This included a situation where a person’s needs had recently changed and in order for them to receive the right support, the provider ensured they had open communication channels with the occupational therapy team and GP service.

The provider told us they worked with a range of other professionals to help make sure people received continuity in their care. This included handover and transition periods for people having short stays in hospital.

The provider focused on continuous learning, innovation and improvement across the organisation. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and people’s individual needs so that they could deliver bespoke support to people.

People were supported to enjoy a full life and be active members of their community. The registered manager and staff had established links with organisations representing people with specific health conditions. This ensured staff had current information on best practice for supporting people.