The Willows Care Home

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• 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 looked at all 7 of the quality statements within the key question of 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 assessment this key question has improved to Good.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff said the manager was very supportive and valued the staff team. One staff member said more frequent staff meetings were needed and more detailed staff handovers. One staff member said, “The manager is very good and supports staff when they need it.” Another staff member said, “The manager takes the lead in showing respect and dignity to people.”

The manager said the service provided a safe, supportive and homely environment for the people who live there. There was an emphasis for staff providing friendly, personalised care to people. The manager said that there had not been regular staff meetings but these were planned. This will help to ensure consistency of good practice. They stated that staff handover information contained sufficient detail to ensure all relevant care was provided.

Staff told us they were happy with the support they received from the manager. They said there was an "open door" policy where they could share concerns, which were listened to and acted on. One staff member said: "The new manager is very good. She will always listen and try to do something to help.” Staff told us they had the necessary training to complete their roles effectively and had the option to develop their knowledge further if they chose to.

The manager was capable and had the capacity to carry out their role. Improvements were being achieved and risks had been managed safely. Surveys had been completed from people and relatives which showed that staff and management were caring and listened to peoples’ concerns and views. The manager had the knowledge to deal with any safeguarding concerns.

We observed a culture where staff and the manager acted with openness, honesty, and transparency. Staff said when they spoke up, they were listened to and heard by the manager.

Processes were in place to enable people and their representatives, and staff to be able to speak up to highlight any concerns, such as the whistleblowing and complaints policy and procedures. The whistleblowing procedure did not include how to contact external, relevant agencies. The manager rectified this by adding relevant details.

The service worked towards an inclusive and fair culture by the manager ensuring there was equality and equity for staff. Staff said they were well treated by the manager and there was no discrimination or favouritism. The service had a diverse workforce in place. Staff felt they were treated fairly and equitably. We heard examples of where staff’s wellbeing had been considered and acted on. Staff had received training in equality and diversity to ensure staff and people were treated equally with their needs taken into account.

The provider’s associated policy was in place to encourage equality and equity for staff.

The people who used the service, their relatives and staff, were mostly satisfied with the governance of the service. They thought the manager was open and friendly and took action to support people and staff. There were reservations expressed about the provider in terms of providing sufficient staffing levels and aspects of the environment in terms of the decoration of facilities.

The service had clear responsibilities, roles and systems of accountability and governance. They acted on information about risk, performance, and outcomes. The provider said there was no recorded quality assurance system in place. However the manager swiftly responded and put an auditing system in place to identify any identified shortfalls of the service.

The service collaborated with the people who used the service and the people that were important to them; people and their relatives felt the relationship they had with the manager was good and consistently open and honest.

Records we viewed demonstrated that the service worked in collaboration with people and staff when they raised concerns. Staff felt they were given the opportunities to influence how the service was delivered though 2 staff said more regular staff meetings were needed. The manager said this had been identified and planned.

Partners told us there had been improvements for example, with care plans, however, they shared their concerns with us in relation to staffing levels and lack of provider support to the manager.

The provider had not implemented quality assurance systems to identify and drive improvements. However, the manager had then swiftly created relevant quality frameworks based on recognised standards and best practices to improve equity in experiences and outcomes for people.

The registered manager shared their aspirations to improve the service. Staff told us they were supported to develop their roles if they chose to.

The manager had implemented relevant learning frameworks based on recognised standards and best practices to ensure a good quality of care was provided to people.