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 assessment we rated this key question requires improvement. At this assessment 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 61 (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 provider sought feedback from staff through meetings, questionnaires and during appraisals. When suggestions were made, action was taken. One staff member told us, “I had an appraisal in May. It was a good experience, I was asked if I had any concerns or issues, I was asked about a lot of things.”

The provider explained their key values. They told us, “I want The Willows to be a home from home, which comes from safety and comfort.”

The provider had inclusive leaders at all levels; however, they did not always have the skills, knowledge, experience and credibility to lead effectively.

The provider had not ensured that all leaders who were responsible for auditing the quality of the service were able to effectively carry out their roles.

Quality monitoring systems were in place but were not always effective. While the provider told us senior staff had received training to complete audits effectively, we still found they had not identified several of the issues raised. Provider and managerial oversight had also failed to identify the concerns.

Relatives held a positive view of the provider and new manager. One relative said, “Things have improved in the home, so I feel the home is being well managed.”

The manager was new to the role and had already driven improvements to the service, however they had not been fully embedded at the time of inspection. They told us the provider had been ‘really supportive’ while they settled into their role and continued to regularly visit the home to support with improvements.

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

The manager and provider had been working with the staff team to ensure they felt confident to raise any concerns, Staff confirmed this. One staff member told us, “I haven’t had any major concerns. For some minor concerns, I spoke to the manager confidentially. They [manager] are a wonderful manager and good at listening. Initially, I wasn’t confident to go to [provider] as they are the owner but over time, we have built a good relationship.”

The whistleblowing policy explained the process of escalating concerns if it was felt necessary to do so.

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 recruited a diverse workforce, policies were in place to support equality and diversity, and staff had received training in this area.

The provider had implemented reasonable adjustments for staff who required extra support to carry out their role, such as purchasing equipment.

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.

During this inspection, we found that a number of audits had not identified the issues we identified, despite being carried out by senior staff, the home manager, and the provider. For example, medication audits undertaken by senior staff and the provider had failed to highlight concerns such as the absence of guidance for creams, for administering a medicine covertly and paracetamol being given within less than the required four-hour interval. In addition, several environmental audits had not identified safety concerns, including an unlocked window restrictor and a damaged crash mat, despite checks being in place to cover these specific areas. Care plan checks had also not identified potential risk to people.

We found some areas of improvement, and the new manager in post had made several positive changes especially in relation to staff support; however, further work was needed to embed good practice.Despite breaches of regulations and concerns having been identified at the previous 9 inspections, there had still not been sufficient improvements made to demonstrate compliance with the regulations.

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 well with other healthcare professionals to ensure people had the right support. The G.P completed a ward round every week, and any concerns were made available to them prior to their round. External healthcare professionals told us they were given the information needed to provide support. One healthcare professional described staff as ‘very helpful’, another said that there were some inconsistencies in the staff team and therefore often spoke to different individuals. However, they generally got all the information they needed.

The provider told us about other external partners they had links with such as advocates and social workers. One person was supported to see a chaplain and the home had had a visit from a therapy dog earlier in the year.

The provider did not always focus on continuous learning and improvement across the service. Although some improvements had been made since the last inspection, these weren’t yet consistently part of everyday practice. More work was needed to ensure the service was effectively monitored and improvements made to ensure quality was maintained.

The provider and manager were responsive to our feedback throughout the inspection and took immediate action to address concerns. However, work was required to ensure they acted proactively to minimise risk and identify issues, rather than reacting to the concerns raised on inspection.