Archived: Willow Home Care Ltd

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 inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to the lack of governance.

This service scored 32 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities. The provider failed to report falls incidents. No accidents or incidents were recorded on documentation between the timescale of April 2025 and July 2025. We raised this at the time of inspection and the manager told us no incidents had taken place. We did not feel assured as on further review of records and speaking with people we found 3 reportable incidents had happened in regard to falls. Some actions taken by seniors and management were seen to be of a closed culture. For example, a service improvement plan was in place, but this only involved family members who worked together with the provider. No neutral oversight was present.

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

The provider and manager had not displayed leadership skills or acted with integrity when incidents happened. They had not been open and honest with staff or people. Staff had been placed in situations where they had come to harm due to not being given the correct information. The provider had acted without consideration for people in their care. The actions the provider initiated following an incident showed they had little regard for people’s wellbeing and had not put their needs as a priority. The provider lacked the experience and skills to deliver appropriate care. The provider had relied on senior staff to lead the service, but they had not shown the skills or knowledge needed to operate the service and promote good care. The manager required further development and support to enable them to provide the appropriate supervision and monitoring of staff. Senior members of staff who were responsible for monitoring the quality of the service had not ensured where poor quality of care was present, actions and reviews were completed.

People did not always feel they could speak up and that their voice would be heard. Staff told us during the assessment they felt they could speak up. However, they didn’t feel they would be listened to or that anything would be actioned appropriately from speaking up. Relatives and people we spoke with did not feel listened to when raising a concern about their care. People told us they found it difficult to gain contact with senior staff in the office. This meant people receiving poor care did not feel they could speak out.

Staff were positive about the provider being inclusive and treating them equally. Where staff were on sponsorships, they were not always supported to have additional development with adjusting to a different culture.

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 relied on the manager to complete an action plan to rectify the shortfalls identified. However, the manager had not completed these actions. The provider had not had oversight of the manager and had not understood their responsibility to check the action was being taken. There were no effective systems or processes in place to monitor the quality of the service, staff practice or to drive improvement. The provider and manager showed a lack of understanding and knowledge about their legal responsibilities to keep people safe and provide a safe service. Since the assessment the provider has provided documents regarding medicine checks, Hierarchy structure. They have also provided sample audits that are now being completed. This will be reviewed at the next assessment.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement. There were no effective processes in place to work with healthcare partners. The provider had not responded or communicated to local authorities when they were contacted to complete a quality visit.

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. They did not actively contribute to safe, effective practice and research. Since our last assessment the provider had not showed any learning or improvements to improve the quality of care. The provider and manager had not identified the concerns we evidenced in this assessment.