Willowbeck Health Care Limited

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 requires improvement. 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.

The provider was previously in breach of the legal regulation in relation to good governance. Improvement was found at this assessment, and the provider was no longer in breach of this regulation.
 

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 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.

There was a positive atmosphere and culture in the service which focused on effective care and support for people.

Managers and staff told us they aimed to give people they supported the best quality person centred care they could.

Leaders were knowledgeable about their regulatory responsibilities and also about the priorities for the development of the service.

Staff were aware of their roles and responsibilities and felt involved in decisions about the service. One staff member said, “My team is really good. We do a lot of teamwork. We plan together and have good communication; it’s a good team.”
 

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.

Systems and processes were in place to provide support to staff which in turn promoted a positive and inclusive culture.

Staff told us management were approachable, and they felt comfortable speaking with them and raising concerns. Staff also said they felt supported by managers. Comments included, “Managers are supportive” and “I like working here. I like the level of support you get here.”
 

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

The provider had an up-to-date whistleblowing policy which was regularly reviewed. This was readily available to staff, being both on display within the home and available electronically. When asked, staff were able to explain what they would do if they needed to escalate concerns. One staff told us, “Feel confident staff would raise concerns if they needed to.”

Systems were in place for people to speak up and for their voices to be heard. One person told us, “I’d speak to staff if I was not happy.” Another told us, “I reported problems to managers.”
 

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 policies and procedures in place regarding equality, diversity and inclusion and staff had received training on equality and diversity.

The provider encouraged and promoted a workplace of equality, diversity, and inclusion. During supervisions staff well-being was discussed and other processes for support and seeking feedback were in place. One staff told us, “We had a staff survey.” We saw follow up to surveys completed, with action plans identifying ‘you said, we did.’
 

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. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The provider had structures in place to monitor and improve the quality of care they delivered.

Audits and quality monitoring systems were used to assess care quality and safety such as care plans, environmental risk assessments, and staff competency assessments.

Audits and governance processes such as the analysis of accidents and incidents, helped ensure the service had an accurate picture of risk to the safety and quality of the service at any one time.

Complaints and incidents at the service were investigated by a team independent from the home. Recent incidents at the service had been investigated with both root cause analyses and lessons learnt completed. We asked the provider to ensure actions taken to mitigate future risk from these incidents were embedded and sustained across the service.

The registered manager was aware of their responsibilities to notify partners. For example, notifications to CQC and safeguarding alerts.

The provider had a business continuity plan which detailed how they would be prepared for emergencies.
 

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.

The senior team had a strong commitment to improving the service and were open to suggestions for improvement, recognising the importance of joint working with partner agencies.

Staff were also aware of the value of working in partnership, with professionals, people and with other staff. One staff commented, “Staff team is good, we work well as a team.”

Records seen evidenced positive working relationships with other professionals. Advice was sought, and referrals were made in a timely manner which allowed continuity of care. Feedback we received was positive overall. One partner commented, “Any (minor) issues there have been dealt with appropriately by the management team/nursing staff.”
 

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.

The senior team worked with people, their families and staff to build a culture focused on improved outcomes for people. One relative told us, “I can talk to them if I have any queries. They keep me updated.”

People and their families were involved in shaping service delivery. One staff told us how people were involved in influencing training provided, “At the moment person is involved in PBS (positive behaviour support) training making sure it is person centred. The training has been tweaked to include what our service thinks of the staff approach and how they could best be supported.”

Staff told us they were encouraged to contribute their ideas about the service and were supported to learn new skills as well as develop in their role. One staff told us, “The transition to [role] was daunting but felt supported enough to take. The provider encouraged me to do that progression.”

The organisation was striving to learn and improve. Learning was embedded through team meetings and audits, and the provider was continually striving to make improvements. The registered manager and senior team were responsive throughout the assessment to further learning and improvements to ensure people received safe and effective care.