Archived: Willowbank Nursing 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 inadequate.At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

At the last assessment, the provider was in breach of legal regulation in relation to systems and processes not being managed appropriately. Improvements were found at this assessment and the provider was no longer in breach of this regulation.

This service scored 64 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service 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. New staff received support and training which helped them to demonstrate the provider’s values in their daily work with people. A relative told us, “I am very dubious about care homes but I’m wrong. I would recommend this one and I think mum would, she said it’s the best decision she has ever made.” The manager was open and honest and told us they were working hard to improve the environment and gave us several examples of the work they had completed since starting at Willowbank, this included a total refurbishment of the dining room. People and staff were encouraged to share their ideas at meetings. People and staff told us they felt listened to by the manager.

The service 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 manager had made several improvements to the running of the service. A staff member told us, “I don’t have any issues with anything there. It’s all very clean as far as I am concerned. It’s a great place and the manager is great.” A staff member told us, “I have personally never had an issue, but if I did, I know I could go to my manager, and he would assist me.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Complaints had been addressed in accordance to the providers own policy and procedures, however outcome documentation was not always fully completed with lessons learnt from any complaints made. The provider had also recorded compliments that had been received about the service People and relative’s comments included, “I would tell them straight away if I had any concerns”, They are open about information.” A staff member told us, “If a resident/relative raises any concerns the manger will happily chat with them to try and resolve any issues.”

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff told us they were able to ask for reasonable adjustments to be made to their working patterns for specific needs, for example to incorporate family commitments.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Audits and checks were carried out in areas such as health and safety, care plans and staff practice. However, where shortfalls were found these were not always actioned for example within the medication audits and the prompt update of care plans following change. The manager acknowledged that further work needed to be undertaken to ensure all finding from audits were implemented. A staff member commented, “the new manager is making the changes that are needed.”

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. We saw some evidence of how the service worked in partnership for people; however, this was not the case for everyone. One relative told us, “It annoyed me that I have completed a thorough life history for them, and I discovered the activity coordinator wasn’t aware of it and approached [relative] to do this and then all the information on it was incorrect.”

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, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. Although there were clear signs of improvements made within the service, this had not been embedded into practice throughout. For example, the risk regarding call bells and short falls in some documentation that could leave people at risk. Processes to ensure that learning happens when things go wrong, and from examples of good practice were becoming established. The manager had a clear plan of actions required to continue to make the improvements required.