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 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.

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.

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.

Leaders promoted a positive and open culture focused on learning and continuous improvement. The management team demonstrated a commitment to developing the service through ongoing review, reflection and engagement with staff. This supported continuous improvement and helped ensure the service responded to people's needs.

The provider embedded its vision and values into day-to-day practice. Team meetings included discussion of the provider's vision and values, and staff demonstrated a clear understanding of the provider's mission, values and statement of purpose. Staff explained how these guided their day-to-day work and supported positive relationships with people. This demonstrated there was a shared understanding of how care should be delivered.

Most staff described a supportive team culture, although feedback was mixed. Thirteen staff spoke positively about working at the service, with a staff member saying, "I love working here. It's like a big family," and another commenting, "The team is friendly and supportive, and everyone works together." However, 4 staff described the culture less positively.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Staff did not consistently experience leadership positively. Although several staff described managers as approachable and supportive, others told us they did not always feel listened to or valued. One staff member told us, "Manager says his door is open... but he never gives his full attention," while another commented, "The deputy can be rude." Leaders told us they promoted an open-door culture and encouraged staff to raise concerns through regular supervision, team meetings and daily engagement. This demonstrated staff experiences of leadership were mixed and not consistently positive.

Leaders demonstrated a clear understanding of their roles and responsibilities. Managers understood legal and regulatory requirements and had identified areas for improvement, which were being progressed through an active service improvement plan. Since our last inspection, leaders had also introduced initiatives to improve staff morale and wellbeing. This demonstrated leaders had oversight of the service and were committed to continuous improvement.

People and relatives spoke positively about leaders. People knew who the Home Manager was and felt able to approach them if needed. Relatives told us the manager and office staff were accessible. This demonstrated leaders were visible and accessible to people using the service and their families.

Staff also described positive changes in leadership. Some staff described management as "fair and just", "approachable and always willing to listen" and reported a "big improvement to the management."

The provider promoted a culture where people and staff were encouraged to speak up and raise concerns.

People told us they knew how to report concerns and felt comfortable speaking to staff. Relatives also knew how to escalate concerns, with 1 saying, "If I had a concern I would tell the manager." This demonstrated people and relatives knew how to raise concerns if they needed to.

Staff understood how to speak up and were aware of the provider's whistleblowing procedures. Up-to-date whistleblowing policies were available, and staff demonstrated a good understanding of how to raise concerns. One staff member told us, "I feel comfortable speaking to the management team if I have any concerns or ideas. They are always willing to listen."

The provider had strengthened opportunities for staff to share feedback and influence improvements. We reviewed the provider's whistleblowing procedures, staff survey, suggestion box and 'You said, we did' board, which communicated how feedback was used to drive improvements.

Some staff described improvements in how leaders responded to feedback. One staff member told us, "We now have a suggestion box and know staff who have used it and seen action taken from it... Management will now listen to suggestions; it's a lot better." Another staff member told us, "I do have a voice and have expressed my concerns... and I do get listened to and respected."

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 promoted equality, diversity and inclusion across the workforce. Policies were in place to support equality, diversity and inclusion and protect staff from discrimination and harassment. These set clear expectations for respectful behaviour and promoted a consistent approach across the workforce. This helped promote an inclusive working environment.

The provider recognised and responded to staff's individual needs. Reasonable adjustments were made where required, including for staff with health-related conditions, enabling them to remain in work and carry out their roles safely. This supported inclusion, wellbeing and staff retention.

Staff consistently described an inclusive and respectful culture. One staff member told us, "A place where we care. Everyone is friendly, supportive, compassionate, respectful, dignified and where everyone respects each other's culture and religion." Another staff member told us, "Cultural diversity is very good. There is no discrimination," while a third member of staff told us, "I have worked in many places but here, for the first time I feel like I am treated like a human being." This demonstrated staff felt valued and included regardless of their background.

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.

Leaders had effective oversight of the service and used governance systems to monitor quality, safety and performance. Information from incidents, complaints, audits and routine monitoring was reviewed to identify trends, inform decision-making and monitor the effectiveness of actions taken. This supported continuous oversight and helped drive improvements across the service.

The provider used governance systems to improve outcomes. Since our last inspection, leaders had implemented new monitoring systems, strengthened management oversight and maintained an active service improvement plan. Governance processes had identified areas requiring further improvement, including staffing oversight, workforce training and aspects of care documentation. Leaders responded by introducing enhanced staffing monitoring, reviewing documentation and delivering targeted workshops to strengthen practice. These actions had resulted in significant improvements, and the provider was no longer in breach of regulations. Although some improvements, including aspects of care documentation and staff experience, were not yet fully embedded, leaders had recognised these areas and continued to monitor progress through established governance processes.

Leaders worked collaboratively with people, staff and partner organisations to monitor performance and respond to changing needs. Where improvements were identified, actions were taken and progress reviewed through established governance processes. Although some staff continued to express concerns about staffing and leadership, feedback from people, relatives and partner organisations consistently described a well-managed service.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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 provider demonstrated a commitment to continuous learning and improvement. They were no longer in breach of regulations, and our inspection found improvements had been made since the previous inspection across risk management, clinical monitoring, care planning, medicines optimisation, the environment, end-of-life care planning and consent to care.

Leaders had strengthened oversight of the service through additional training and the introduction of new monitoring systems. These strengthened governance arrangements and enabled leaders to monitor the quality and safety of care more effectively.

Staff recognised improvements had been made since the previous inspection. A staff member told us, "Big improvement to the Management," while another commented, "Learning from our CQC visit it's improved." This reflected the provider's commitment to learning from previous findings and embedding improvements across the service.