Willowcroft Care 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 provider was in breach of legal regulation in relation to governance at the service.

This service scored 54 (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.

The registered manager described how they supported people to make informed decisions and involve external professionals and families where appropriate. Whilst they told us there was a commitment to providing person-centred care, this was not consistently reflected across all aspects of the service. Care planning systems, monitoring processes and environmental management did not always support this vision in practice.

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.

Leaders were visible within the service and responded to issues raised during the inspection. However, improvements were often reactive rather than proactively identified through effective governance systems.

The registered manager did show compassion and a desire to improve the service; however, concerns found during the inspection had not been highlighted or addressed prior to CQC visiting. Concerns were found across multiple areas, including care planning, environmental risks, maintenance and monitoring systems.

This meant leaders were not always able to ensure the consistent delivery of high-quality care.

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

Staff told us they felt confident in raising concerns with the management team.

They told us they could speak openly with the management team and would be supported to raise issues where required.

People and family members also told us they felt able to raise issues or concerns with staff or the management team.

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.

Policies were in place to support equality, diversity and inclusion. Staff told us they felt they were treated fairly and the management were supportive of their needs.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider had ineffective auditing systems in place, which had not highlighted the significant shortfalls outlined throughout this report. Governance systems were in place but were not effective in identifying and addressing risks. Futhermore, on reviewing the provider’s safeguarding record, we found they had not always notified CQC of notifiable incidents.

Monitoring systems, including audits and checks, had not consistently identified areas of risk. For example, gaps in care planning, incomplete documentation, and continued environmental concerns had not been effectively addressed, resolved or sustainably improved. This meant that audit processes were ineffective and did not drive improvement.

This meant there was a continued risk of harm within the service.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. Staff engaged effectively with external professionals and followed their recommendations.

People were supported to access medical services when needed, and staff worked closely with GPs, community nurses and other healthcare professionals to ensure people’s health needs were met promptly. Information was shared appropriately, enabling external professionals to understand people’s needs and provide consistent care.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people.

Leaders did not always demonstrate a clear understanding of how to drive improvement within the service. Although staff were committed to provide good care, the systems needed to support meaningful learning and development were not embedded. This limited the provider’s ability to make sustained improvements or ensure that good practice was consistently applied.

Although the provider had taken steps to improve the service, these were not always sustained or embedded into practice. Lessons learnt from previous concerns had not effectively been implemented for sustained improvement within the service.