The Willow

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.

This is the first assessment for this newly registered service. This key question has been rated 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 culture of the service is person-centred.

The service aimed to provide professional care in a “home from home” environment. We observed the service to be very homely, and this impression was consistent in all feedback we received. Staff and partners described the service as “a good team” and said they felt part of a family. Staff told us “If it gets to a point where I have to say I don’t think this is working, we try and come to some solution.” This meant staff and management were able to work together to improve the service.

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.

Staff told us they felt well supported by the management team and “the deputy manager is new to the organisation but is good at their job and gets on well with staff.”

Families told us “[The registered manager] is almost always around and available if I need to see [them]. [Their] office is in the garden which I think is a nice touch” and “[The registered manager has] been here every time we’ve called in so far, either in [their] office or in the lounge chatting to residents.”

Partners told us they “always found the home to be well organised and run.” People told us they knew who the registered manager was. We observed leaders engaging with people in a kind and caring way.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they were listened to and felt confident in speaking up. A whistleblowing policy was in place which staff had access to on their phones. Regular staff meetings took place, and records were clear, contemporaneous, and the most recent displayed on the notice board for people to see. There were multiple ways to give feedback via suggestion boxes, meetings and formal compliments or complaints.

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. There was no evidence of discrimination. Staff told us they felt valued. Staff had received equality and diversity training.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They acted on information about risk, performance, and outcomes, and shared this securely with others when appropriate. Staff and management demonstrated a strong commitment to delivering high-quality care that was person-centred, inclusive, and responsive to individual needs.

Care plans did not always reflect the most up-to-date information regarding peoples’ needs and reviews were not clearly dated. Care plans contained information that was no longer relevant to the service or to people living there. Risk assessments lacked detail and written strategies for staff to support people to mitigate risks around positive behaviour support, moving and handling, and falls. Management had identified issues around recording of daily records, care plans, and risk assessments. They have taken steps to address this with the electronic care planning provider, and organised further training to staff.

Infection control and medication management audits were regularly undertaken, however, other audits around health and safety, care plans, and call bells had not been completed.

Personal Emergency Evacuation Plans (PEEPs) for all residents were completed and contained in care records and the emergency fire evacuation bag, however, were not individualised and did not contain up to date information regarding changes in health needs and mobilisation.

There was a business continuity plan available although there was no record of this being tested.

Spot checks were undertaken but not documented. Records of monthly visits carried out by the Nominated Individual were available but did not provide clarity of actions needed to be completed

Mental Capacity Act 2005 assessments and best interests’ decisions were made, however, were not documented accurately, and lacked clarity as to whether a person had been deemed to have capacity.

This meant there was poor oversight of the service and day-to-day operations. We have given feedback to the provider about the governance of this service.

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 service worked in partnership with multiple stakeholders in the local community as well as health professionals and the local authority. Partners told us the communication from the service was important and they did it well. We saw evidence of many visits to the home by partners, however there was no evidence of planned visits into the community. Residents were enabled to leave the home on outings with their families or representatives.

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 organised mock inspections of the service to drive improvement. The leadership team were proactive in addressing issues, for example, with the electronic care planning system and daily record noting. The service held a service-wide action plan as a result, but it did not include areas such as PEEP or MCA documentation found on the day of inspection.