Willow Court 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 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.

The service was in breach of legal regulations in relation to good governance. Leadership and management were inconsistent. Governance systems did not operate effectively and had not identified care planning, risk, medicines management, or environmental shortfalls identified during this inspection. Records were not consistently complete or accurate, and oversight processes had not driven sustained improvement.

This service scored 50 (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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Staff feedback indicated a culture of blame and reprisal, where mistakes were highlighted rather than used as opportunities for learning or reflective practice.

A staff member told us, “The staff team on the floor are dedicated and caring, but the overall culture feels pressured and unsupportive. There is a focus on keeping things running smoothly without addressing underlying issues such as staffing [and] morale”. Twenty-four other staff members told us concerns were often dismissed and that issues raised did not result in meaningful action. This contributed to low morale, disengagement, and a workforce that felt undervalued and under pressure.

Our findings, including incomplete care plans, inconsistent risk assessments, medicines governance concerns, and the failure to embed learning from incidents, indicated that problems were not consistently identified, shared, or resolved. Staff uncertainty about the service’s overarching priorities and values contributed to inconsistent approaches to care and decision-making, limiting opportunities for staff to contribute ideas or work within a cohesive, values-driven culture.

The provider acknowledged the need to develop a clearer vision and shared culture. They outlined plans to engage staff more actively in defining service values, strengthen leadership communication, and embed principles of equality, diversity, and inclusion into everyday practice.

Not all leaders had a clear understanding of the context in which the provider delivered care, treatment, and support. Leaders did not consistently embody the organisation’s values or the culture expected by the workforce.

The registered manager demonstrated awareness of their legal responsibilities, including obligations under the Mental Capacity Act 2005. However, we found gaps in practical application. For example, the absence of decision-specific Best Interests documentation indicated that MCA knowledge had not always been fully embedded in day-to-day practice. This contributed to inconsistent decision-making and affected the extent to which people’s rights were consistently upheld.

Additionally, inconsistencies in leadership contributed to low staff morale and disengagement, which in turn affected the quality and consistency of care. Staff told us that whilst most leaders were compassionate, guidance could at times, feel dismissive. For example, a member of staff told us, “when talking to the manager he is walking away while you are talking”. Another member of staff said, “if we try and speak to the registered manager about our concerns, he will tell us where the door is and walk away”.

The provider acknowledged these gaps and outlined plans to strengthen leadership and governance. Actions included reinforcing staff training, reviewing the application of the Mental Capacity Act 2005, implementing more proactive governance systems and fostering a more supportive, inclusive culture.

People did not always feel they could speak up and that their voice would be heard.

Staff told us when they raised issues, their concerns were sometimes dismissed or met with negative responses. For example, one member of staff said, “When issues are raised [about peer conflict, staff allocation and work pressures], some staff are warned to be careful, as their concerns could be perceived as bullying. As a result, many staff choose to remain silent”. Another staff member stated, “Staff rarely raise genuine concerns during supervisions or meetings because they feel nothing will change”.

The provider acknowledged these gaps and had taken steps to strengthen staff voice. Actions included reinforcing formal processes for raising concerns, providing guidance on reporting and whistleblowing, and promoting a culture in which staff are encouraged and supported to share insights to improve safety, quality and staff’s wellbeing.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

During the inspection, we observed examples of reasonable adjustments being made for staff using the service, and the provider demonstrated a commitment to inclusion and equity within the workforce.

However, staff feedback indicated that these principles were not consistently applied in day-to-day practice. Many staff reported low morale, limited psychological safety, and a culture where mistakes were sometimes met with blame or reprisal. As a result, not all staff felt valued, respected, or supported in their roles.

The provider acknowledged these gaps and had taken steps to strengthen equality, diversity, and inclusion in practice. Actions included reviewing workplace culture, promoting staff wellbeing initiatives, reinforcing training on inclusive practices, and encouraging open dialogue to ensure that staff feel respected and able to contribute fully to safe, person-centred care.

The provider did not have clear responsibilities, defined roles, or effective systems of accountability and governance. They did not consistently act on the best information about risk, performance, and outcomes, nor share this information securely with relevant parties when appropriate.

Governance systems were in place but often failed to identify risks or drive improvements. Care plan audits did not consistently detect missing or inaccurate information, including absent plans for COPD, cognitive decline, behavioural needs, or choking risks. Monthly care reviews were sometimes incomplete or updated overnight, limiting opportunities for people and relatives to participate. Risk assessments were generic, incomplete, or out of date, and records did not always reflect significant clinical risks such as pressure injuries, constipation, or respiratory failure.

Record-keeping and documentation were inconsistent. Care plans were sometimes missing, contradictory, or lacked person-centred detail. Best-interest decisions were incomplete or absent, and consent forms were expired or missing. This meant we could not be assured people’s rights and preferences were consistently respected.

Medicines management was unsafe in multiple areas. Medicines were stored in bedrooms and en-suites without risk assessments, including items placed near oxygen. Documentation was incomplete or inconsistent: MAR charts were often illegible, allergy information was vague, and blood glucose monitoring and insulin administration were inconsistently recorded. Signatures were missing for multiple people. Daily stock checks, ordering processes, and medication policies were not consistently followed.

Leadership and oversight were reactive rather than proactive. Staff reported low morale and a culture of blame, with concerns sometimes dismissed or met with negative responses. Repeated audit findings were not addressed, and learning from incidents was not embedded. Oversight of care plans was weak and referrals to external professionals were sometimes missing.

People did not directly identify any governance issues, however, shortfalls in oversight created ongoing risks in medicines management, care planning, environmental safety, and person-centred care. Incomplete documentation increased the likelihood of inconsistent care, delayed pain management, and insufficient monitoring of clinical risks. Governance shortfalls also contributed to low staff morale, reduced capacity for proactive care, and inconsistent engagement with people’s preferences.

Following feedback, the provider introduced improvements, including shared access to electronic to support monitoring, dashboards for safeguarding and complaints, and strengthened audit processes. Care plan reviews, workshops, learning events, and reflective sessions for staff were scheduled. A Quality Lead was appointed by the local authority to oversee care planning, risk management, wound care, and audits. Medicines audits, risk assessments, storage, and documentation were enhanced, and staff training and competency checks, including for agency staff, were carried out.

While the provider has taken significant steps to strengthen governance systems, these improvements are not yet fully embedded. Shortfalls in oversight, documentation, and staff support continue to present risks.

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.

Staff communicated effectively with healthcare professionals, therapists, and community services, supporting timely and coordinated care. Healthcare professionals provided positive feedback, noting that the service engaged proactively, shared updates promptly, and contributed constructively to collaborative care planning.

These partnerships meant people received coordinated and responsive care, informed by a shared understanding of their individual needs. This approach reinforced a culture of collaboration, continuous improvement, and integrated care across services.

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.

Systems were in place to monitor and review practice, and management had taken steps to strengthen these systems following inspection feedback. For example, information about incidents, accidents, complaints, and safeguarding was now stored in a central folder and recorded on a spreadsheet, improving the organisation and accessibility of lessons learned. The provider had also introduced a wellbeing programme to enhance people’s experiences and provide more meaningful activities.

Although these improvements were being made, some practices remained inconsistent. Care plans and risk assessments were not always updated in a timely or fully comprehensive manner, limiting the translation of learning into improved day-to-day care. Although we found some evidence of innovation and investment, further work was required to ensure that lessons learned consistently resulted in better outcomes for people.