Willett Lodge

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 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 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service 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. Staff meetings were held by department and roles to ensure the agendas were relevant to attendees. Full staff meetings were also conducted with focussed themes to discuss and share lessons learned from events. The registered manager told us of the importance of staff abiding by the values and said, “Their (people’s) lives does not finish when they are admitted into the care home, they are just sharing a house with other residents and have a meaning and meaningful life."

The service 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 effectively. They did so with integrity, openness and honesty. The registered manager was supported by a deputy manager, quality manager and the nominated individual. The registered manager networked with other managers of the provider’s other services to share ideas and provide mutual support. People and their relatives told us they felt the service was run by capable leaders; staff echoed this. Comments included, “[Registered manager] is very caring very good and helpful. They care about everyone.” And, “I think it is very good, the care is excellent, the management team are wonderful and lead us well. The residents are well cared for.”

The service fostered a positive culture where people felt they could speak up and their voice would be heard. There was a supervision matrix in place which enabled staff to speak up confidently with their line manager, although staff told us they could speak with any manager at any time. A staff member said, “They are good they ask me if I have any concerns and I tell them if I do. I have been happy with the way my concerns have been dealt with. They responded to what I complained about.” The provider’s whistle-blowing policy was clear for staff to follow if they had concerns.

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 valued and could voice their ideas and suggestions any time. A staff member said, “Management are very good, I have only had good experience with them. Any concerns I have raised they have addressed it as already spotted it or actioning something straight away. They are a good management team.” Where needed, shift patterns were planned to suit staff’s family commitments, staff told us they appreciated this consideration. Staff’s culture and religion were respected, for example, space and time to worship was available to staff when needed. Although staff spoke a good level of English, it was not the first language of some staff members. The management team changed the training provider to one who supplied accessible training. This benefited staff as courses could be translated into all languages and aided some staff who struggled with online training or had additional learning needs.

The service mostly had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes; however, they did not always share them securely with others when appropriate. Not all statutory notifications had been submitted to CQC in respect of allegations of abuse. Safeguarding investigations were escalated to the local authority and outcomes were logged and addressed thoroughly. The registered manager advised not notifying CQC where the concerns did not meet the local authority’s threshold was an accidental omission. CQC were informed of all other events in the service in line with our regulation. Managers and senior management from the provider’s head office conducted audits and devised service improvement plans based on their findings which were effective. However, they had not identified that statutory notifications for allegations of abuse were not always submitted to CQC.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborate for improvement. The nominated individual was a director of West Sussex Partners in Care which enabled them to cascade new practices to the service. The registered manager attended industry relevant seminars and forums and was involved in setting up a care home support group with the local GP surgery. A visiting healthcare professional told us, “The management team attend regular surgery meetings and provide support for other care homes locally, sharing good practice. The management team always appear approachable and responsive to any issues that may arise.” The wider community was welcomed to the service for events. On the day of our visit, children from the local nursery visited to delivery Christmas cards to people. People also visited another of the provider’s care home for events and parties.

The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research. The provider shared their vision of continual improvements and innovative practices using technology. Although audits were conducted in the service, the service was trialling an artificial intelligence (AI) system to quality check care planning. This was done alongside manual audits to check effectiveness and efficiency before committing to using the system. The service engaged with external consultants to provide a view on compliance and performance, suggestions and comments were taken seriously. An action plan was developed based on their findings and clearly set out progress made and timeframes for areas to be improved; most actions had been completed by the time of our visit. Computerised systems and dashboards were used for reporting and follow ups from audits and checks. These provided the clinical team, management team and provider’s senior managers a thorough understanding and full oversight of the service. The provider and their management team attended care shows and conferences and took forward learning and innovative ideas. The provider placed a high emphasis on reducing their carbon footprint and made changes within the service. For example, they reduced chemicals in cleaning products, increasing recycling and made adjustments, such as, changing bulbs to LED.