Deben Willow Care

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 remained/changed to 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 68 (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 registered manager was committed to continuous improvement and was working on making sure the provider’s vision and values were embedded and upheld by staff. They had made amended the induction process and meeting structure to better support the diverse staff team

The provider had not always ensured that all leaders understood the context in which the service delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Previous 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. This had at times impacted on the consistency of the service. The new registered manager was working with the provider to address this and lead by example.

Staff feedback was positive about the registered manager and the support they provided but acknowledged that in the past with previous management arrangements they had not always felt supported in their role. One member of staff said, Yes, I feel valued by my colleagues, supervisors and new manager. My opinions are heard, and my work is recognized. This motivates me to keep giving my best.” Another member of staff shared, “I feel there is a significant disconnect between frontline staff and senior management. Longstanding issues have gone unresolved, which has affected my overall experience. Despite this, teamwork among colleagues is generally supportive.”

There was mixed feedback from people and relatives about the visibility of the leadership team. There had been several management changes including office personnel and this had at times disrupted the service and continuity of care. People and relatives shared past experiences of their issues not being addressed with one person saying, “I’m changing my provider next week. I’ve had enough, not the carers but the managers; they tell you anything but do nothing. I can’t trust them.” A relative shared, “I can’t remember the last time a manager either rang or called in to discuss any long term trends.”

A 2 week rota had recently been rolled out to people in response to their feedback of not knowing which care staff to expect and when, the registered manager had followed this up by contacting people and where applicable their relatives to check if it was working, using this as an opportunity to check they were happy with the service and to introduce themselves. The registered manager advised that feedback overall had been positive about the rota. They told us people had shared examples where care staff were singled out for praise for their compassionate approach and attitude. They also confirmed that no one had changed care provider and cancelled their service and where some inconsistencies had been brought to their attention these had been resolved. Records seen confirmed this.

We were encouraged by the actions taken by the registered manager to increase their visibility and to provide effective leadership and stability in the service. This was a work in progress at the time of this assessment and needs to be fully embedded into the culture of the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Systems were established for all staff to speak up if they needed to and to share any concerns. One member of staff said, “It’s a good place to work, I am able to speak freely.” Another shared, “The culture is positive and open. There’s a supportive atmosphere where I feel comfortable speaking up and being myself.”

All staff had been provided with training and information on whistleblowing during their induction and had access to the provider’s whistleblowing policy. Whistleblowing is the act of raising concerns about those who are vulnerable e.g. people who use the service, colleagues, or the wider community, protecting them from potential harm, risk, malpractice, or illegal activities within a social care setting.

Staff felt confident that any concerns raised would be taken seriously and investigated. We found where concerns had been raised, they had been investigated fully with outcomes shared with relevant people. The registered manager told us they encouraged staff to share any concerns and acted on all information received.

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 ensured staff had fair treatment and equal access to opportunities, regardless of any protected characteristics. Staff mentioned the culture of the service was good, morale was high, and there was an inclusive environment where they felt welcome. One member of staff shared, “I would recommend working for this service. It can be challenging work, but it's incredibly rewarding. The team is supportive, and there's a strong emphasis on compassion, professionalism, and making a real difference in people’s lives. There’s also a good structure in place for training and development, which helps you feel confident in your role. Teamwork is going well. We help each other, communicate openly, and share responsibilities based on each person’s abilities. There is mutual trust and respect within the team. There is good communication, clear task delegation, and support from leadership. We also regularly reflect and evaluate together, which helps us understand each other and improve where needed.”

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

The provider acknowledged that there had been disruption at times in the service due to staffing changes, rota inconsistencies and not having enough resources in the office to support with effective monitoring and oversight of visits. The provider was supporting the new registered manager to address the staffing inconsistences and historical issues with leadership through active recruitment. This was ongoing to ensure there was enough staff both care and office based to meet people's needs, cover absences, sickness and provide continuity of care. In addition, the registered manager had recently been appointed to provide stability and support in the office and within the service.
The registered manager shared their action plan for developing the service which included plans for improving the arrangements in place for overseas workers to assist with their integration and understanding of cultural differences.

Following an internal review of planned and delivered visits the registered manager was implementing changes to strengthen exisiting systems. This included ensuring the coordination of visits reflected sufficient travel time and breaks for staff and increasing the management oversight through monitoring and reporting to include any late or missed visits to identify themes quickly and to respond appropriately.

A range of audits were in place with action plans to address improvements needed. Accidents, incidents and safeguarding concerns were reviewed to help keep people safe and ensure appropriate action was taken.

There were opportunities for people and their family members to provide feedback on the service through care reviews, quality assurance systems and speaking to the office if they had any concerns. In addition the registered manager was going out on visits, reviews and carrying telephone welfare calls to get to know people and relatives within the large service. One person said, “I just know that when we have had a problem, it’s been sorted out promptly.” Another person said, “I have a good relationship with the agency, I really like them. We talk through any little issues, and we are asked for feedback. They have newsletters that tell you what’s going on.”

The provider understood and carried out 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.

Management had established good partnership working with various organisations and external stakeholders to provide positive outcomes for people. One professional shared, “We currently have no concerns with Deben Willow Care. New manager in post and the service is working openly and transparently with the local authority.”

The registered manager knew who to contact if people required additional support from other healthcare professionals such as GPs, district nurses and hospice staff.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.