The Willows 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. The registered manager told us the culture at the home had improved and there were plans in place to bring the community back into the home to improve people’s quality of life. Staff told us they valued working at the home and described a culture of teamwork. A staff member told us, “The culture here now is much better activities have improved, and people are much happier I think.” Relatives also spoke positively about the culture. A relative told us, “All of the family agree [person’s name] has received great care here. The cleaners are part of the team. A big part of the team. It’s more like a home from home, not a nursing home.”

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. Staff told us they were confident with the management team. Staff described the registered manager as approachable and supportive. People felt able to raise concerns or queries with the registered manager and felt these would be addressed. We received positive feedback from relatives about the nursing staff and the support their family members received. The registered manager understood their responsibilities and had systems in place to ensure people received the care and support they needed. Where required notification of incidents were submitted to the appropriate body, including the CQC.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The registered manager told us they had a freedom to speak up process in place. The registered manager said, “We have freedom to speak up champions in place to raise things on behalf of other staff who maybe lack the confidence to raise things themselves.” Staff were aware of these champions but told us they would be confident in raising concerns themselves. We saw there was a whistleblowing policy in place and staff were aware of how to raise concerns, including with external agencies if needed.

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 a policy in place which set out how they would ensure staff had equality of opportunity with regards to employment. There were systems in place to ensure staff’s protected characteristics were considered. Staff confirmed these policies were followed and they felt supported working with the provider.

The provider had systems in place to check on the quality of the care people received. However, these were not consistently effective. People and their relatives told us they were unclear on how they could be involved in sharing their views about the service or be involved in identifying improvements. Relatives told us whilst things had improved there was more to do. A relative told us, “The registered manager is new. There still needs to be some improvements made. There was no hairdresser, there is one now. There needs to be more stimulating activities for those who can join in.” Other systems were in place and working to ensure people’s needs were met for example, the electronic records system was audited monthly to check peoples care records and care plans were up to date and accurate. Any areas which required update were noted and actioned by the registered manager. Medicines audits were in place, and these checked on the safe storage, administration and recording of people’s medicines. The registered manager told us they had introduced a planned care system within the electronic record which set out when people needed to have various aspects of their care needs met. The system ensured staff were prompted to deliver the care and complete the care record. The registered manager told us this had improved compliance with record keeping. Records we saw supported this.

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 registered manager told us they worked in partnership with a range of other agencies. The provider had worked with local partners to identify areas for improvement and complete an action plan to ensure these improvements were made. Training had been accessed from partners, including face to face training for end-of-life care and training relating to sepsis for all staff to improve early recognition. There were also regular audits in place from external agencies, for example to check on infection prevention control measures.

The provider had systems in place to look for continuous learning, innovation and improvement. The registered manager described how they used different approaches to identify learning to make improvements. This included checks from partners on the service, safeguarding incidents, complaints and their audits to identify areas of improvement and make changes to the service. The provider had taken on board the feedback from the last inspection and made improvements. There had been changes to the décor in the home, changes to menus, increased activities and increased recruitment of nursing staff.