Willoughby House

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

We identified 1 breaches of the legal regulations. The oversight by the registered manager and provider did not support a high-quality service. The registered manager’s and staff’s knowledge about what a good day would look like for people was lacking and therefore the care provided did not support the provider’s vision to support people to live independent lives. The providers policies and procedures were not sully embedded to support good care.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us they liked working at the home. They were aware that the provider’s vision for the home was to support people to lead independent lives. Staff were caring for the people they supported and wanted the best for them. However, while staff understood the provider’s vision, they failed to live by it. As mentioned in other sections of the report, staff lacked the knowledge to support this vision, they failed to identify risks or areas where people could be supported to become more independent.

People’s care plans did not fully support the vision of people leading independent lives, or to improve the independent living skills. Reviews of people’s care plans had not included the person or their relatives to identify areas where people’s independence could be supported.

The registered manager was knowledgeable about the needs of people living at the home. However, at times they lacked the insight into the latest best practice in supporting people with a learning disability or autism. For example, people’s ability to make decisions had not been properly assessed or recorded, care plans did not fully identify risks, people’s independence was not always promoted and environmental risks had not been fully mitigated. Staff we spoke with were complementary about the registered manager. They told us the registered manager was supportive and available to them.

The provider has policies and procedures in place. However, the systems in place were not always robust enough to ensure policies were followed. For example, staff had not always followed financial policies. Care plan updates were not signed or dated so it was not possible to identify when the change took place or why.

Staff knew how and where to raise concerns. They told us they felt comfortable to raise concerns and were confident that action would be taken to address the concerns.

The provider had processes in place to support staff to raise concerns if there was anything they were worried about. This included a whistleblowing policy and a safeguarding policy. Regular meetings were held where staff were enabled to discuss their views and opinions . However, the provider had not always followed their own policy when staff had raised concerns at their other homes so we could not be confident they would listen to any issues raised and take action to keep people safe and improve the care provided.

Staff told us they felt fully supported by the registered manager and that when needed they needed accommodations in their working lives the registered listened to them and worked with them to meet their needs.

Staff had access to equality and diversity policies and guidance. These aimed to ensure reasonable adjustments could be made to meet needs such as caring responsibilities or emergency leave requests.

Staff told us that they regularly completed audits. One member of staff told us, “Everything is all completed so that we know where everything is.” Areas where improvements were needed were discussed in staff meetings so that all staff were aware of the actions needed. Despite staff being clear that audits were completed and actions taken we found at times they lacked the knowledge to complete audits appropriately. For example, a member of staff told us best interest decisions were within the DoLS and no separate ones were needed. This meant people could not rely on staff to ensure everyone had been consulted and decisions made correctly. This lack of staff knowledge in areas meant they could not be relied upon to identify areas of concern when completing audits.

The registered manager had systems in place to monitor the quality of the care provided and environment. However, these were not fully effective and did not support people to receive high quality care. For example, environmental issues had not been identified prior to our assessment. Care plan audits had not identified risk assessments were not in place for all identified risks. Systems to monitor and review incidents and accidents in the home had not been used correctly and consequently incidents were missed and opportunities to improve care were missed. Where incidents were identified the analysis of incidents were poor and actions identified were reactive to a similar incident taking place and not proactive to stop an incident from occurring. Staff recruitment documents were not always available, for example, one person had no photographic documentation to show their identify had been checked. The provider failed to provide adequate oversight and support to the home. There had been no identification at provider level that the systems within the home had not been effective. In addition, learning at the provider’s other homes had not been shared to drive improvements in care and best practice. This meant the service people received was not always in line with best practice guidance.

Relatives told us staff supported their loved ones to make appointments or visit health and social care professionals. The staff team worked with other professionals to provide a service which met the full range of people’s individual needs.

The registered manager and staff confirmed that they had a good working relationship with the local doctor’s practice. They also felt confident to contact social workers about any concerns they had about people’s care and worked with them to find solutions to support people’s needs.

External agencies we spoke with were confident the registered manager and staff worked with them to ensure good outcomes for people.

Arrangements were in place to ensure staff had a good level of partnership working with other agencies and professionals. Relevant information was shared with professionals as required. The registered manager and staff were open and transparent during this assessment process and engaged fully with the inspection team.

The registered manager and provider told us how they took lessons learnt from incidents and shortfalls within the service. However, we found that not all incidents had been identified by staff, therefore learning opportunities had been missed.

Systems were in place to provide training and support to staff and to learn from incidents. However, they were not effective at driving improvements. For example, staff training had not ensured staff were fully aware of what constituted an incident. In addition, in addition staff had not had their competency checked after completing training to ensure they had fully understood how to care for people safely. The provider had not ensured learning identified at other homes the provider owned was shared. This meant opportunities for improvements had been missed.