The Willows

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 inspection we rated this key question requires improvement. At this inspection the rating has remained 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 service remained in breach of legal regulation in relation to governance of the service.

This service scored 57 (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.

Processes to involve people and staff in developing the culture included seeking people's feedback on the quality of care and service provided, through meetings and questionnaires. Where suggestions were made, some action was taken. However, based on the feedback we received, further work was needed to ensure people’s feedback was listened to and any actions taken were reviewed to ensure they led to improvements in the quality of the service people received.

The management team supported an open culture and had created a team ethos. Staff spoke positively about working at the home and felt supported in their roles. One staff member told us, “We are a team, and we are really improving. It’s the little things that matter.” Another staff member said, “We are 1 big team. We all support each other. That includes the manager, we have to work as a team to make improvements."

The provider had inclusive leaders; however, they did not always have the skills, knowledge and experience needed to ensure they maintained effective oversight of the service. Quality monitoring systems in place were not always effective, as they had failed to identify the issues we found. For example, fire safety concerns were identified again at this inspection.

While systems were in place to guide staff on the expectations of their role, responsibilities and tasks, many of those delegated tasks had not been completed effectively. We saw audits had inaccurately reported compliance and did not escalate the issues we found for example, the poor standards of cleanliness in the kitchen. Governance systems and managerial oversight had failed to identify and address these issues to ensure the environment was safe prior to our inspection feedback.

People knew who the management team were. One person told us, “If I had any issues I’d get the manager.” Another person said, “The manager is alright, if I need to, I can speak to them.”

Staff told us they felt supported by the management team. One staff member said, “The manager is very open and will listen to your thoughts and ideas. When something needs to be done, they do it straight away.” Another staff member told us, “The provider does visit. They go round and check things. I know they have meetings with all the managers, but I don’t know any more than that."

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

Staff felt confident to raise any issues or concerns with the management team if needed. One staff member told us, “We can raise concerns in meetings. They happen monthly and we also have daily handovers.” Another staff member said, “Yes, I feel able to raise any concerns and know they would be acted on.”

The registered manager understood the need to be open and honest when things went wrong in line with their responsibilities under the duty of candour.

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.

Staff told us they felt included in decisions about the service and enjoyed working for the provider. One staff member told us, ““Equality is very important. No specific person is treated favourably.” Another staff member said, “Management and seniors don’t so favouritism. It should be equal with all staff. Everyone is important. We work as a team.”

All staff had received equality and diversity training. The provider’s policies promoted equality and diversity, and a diverse staff team has been recruited to support people living at the service.

The provider did not have clear responsibilities, roles and systems to manage effective governance. Through their own quality assurance systems, they did not always act on the best information about risk. Governance arrangements at the service were not effective and failed to ensure effective oversight on the safety of the service.

During this inspection, we found a number of audits had not identified the issues we found. For example, the most recent ‘daily walkaround’ undertaken by a member of the management team dated 03 November 2025 recorded ‘The kitchen was clean and tidy’, this was inaccurate and conflicted with our inspection findings.

Some equipment in place to mitigate the risk of injury from falls were unsuitable. For example, some people had short mats in place which provided insufficient protection from injury, should the person fall out of bed.

This inspection is the 8th consecutive inspection we have found the service was not meeting the requirements of the regulations. This was a continued breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found some areas of improvement for example, the handling and recording of complaints about the service. Following a reallocation of duties staff told us they had more time to spend interacting with people. However, this was not consistent as we observed, during our inspection, some people’s requests for support being ignored by staff.

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.

Staff worked in partnership with health and social care professionals to ensure people had the best outcomes for their health and wellbeing. One staff member told us, “We have a GP ward round every week so we can discuss any issues then.”

People confirmed this. One person said, “The doctor comes in weekly. I have cellulitis and the district nurse comes in to do my legs."

The provider did not always focus on continuous learning and improvement across the service. While some improvements were evident following our last inspection. These had not consistently been embedded into practice and further improvement was needed to ensure the provider was monitoring the service effectively and governance processes strengthened to ensure any action taken in response to safety and quality concerns were maintained.

The provider and management team were responsive to our feedback and took some immediate action to address the concerns we identified during our visit.

Staff recorded incidents and accidents. These were reviewed by the registered manager and action taken to prevent reoccurrence. Any lessons learnt were discussed in team meetings.