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

The provider was in breach of the legal regulation relating to good governance. The service had several overarching quality assurance processes in place, however these had not always been accurately completed. The registered manager had not identified that internal audits were consistently scoring full marks despite this being incorrect, therefore we were not assured their level of oversight was sufficient. We identified some evidence of a poor culture, which impacted communication between staff and leaders. Whilst some staff felt able to make use of the providers internal processes for raising concerns, others were fearful of repercussion and chose to speak with us anonymously. When things went wrong, processes designed to drive improvement had not always been effective, and as a result action had not been consistently taken in response.

This service scored 43 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We found some evidence of a poor culture within the service. Some staff we spoke with were unhappy, and spoke at length about poor partnership working between themselves and the leadership team at the service. Further work is required to understand the reasons for the relationship breakdown, and we asked the provider to investigate further.

The registered manager had a clear vision for the service. They spoke about wanting to enable people to live fulfilling lives, as independently as possible. These values were also supported by the providers values. Staff we spoke with did not refer to the values of the registered manager or provider, however spoke passionately about their own values, and how they aim to support people living at the service.

Processes to support a positive culture were in place, such as regular staff supervisions and staff meetings. However, these were not always used to their full potential. For example, the minutes from staff meetings demonstrated meetings were only focused on tasks. They did not discuss the direction and culture of the service despite this having been discussed in meetings amongst the management team. Staff we spoke with did not describe the overall vision for the service, however had their own thoughts and values. As the shared vision and strategy for the service had not been regularly discussed with staff, we were not assured processes were sufficiently embedded in order to achieve this.

We received mixed feedback from staff in relation to the leadership at the service. One staff member we spoke with said the leadership team within the home had created a poor culture, and they were unable to speak up without fear of retribution from the registered manager. Another staff member said they felt the registered manager did not action things in a timely or transparent way, and felt the service was deteriorating under their leadership. Other staff we spoke with said the registered manager was available should they need additional support, and spoke more positively about their experience.

The registered manager said they felt well supported by the provider, particularly their Quality Team, who they could approach for guidance where needed.

Staff meetings were happening regularly, however were task focused and did not reflect a two-way discussion between staff and leaders. The registered manager made us aware of culture issues amongst the staff team in response to our feedback but felt this was only due to specific staff who had chosen to leave the service. However, evidence collected as part of our assessment suggests this to be a wider issue which the registered manager was unaware of.

We received mixed feedback from staff on whether they felt able to speak up. Some staff told us they could approach the manager confidently. However. we also received feedback from staff who did not want the service to know they had shared their experience with us. This feedback was negative, and spoke about a closed culture within the service. When we shared the themes of these concerns with the provider, they told us they felt this was instigated by a person due to leave the service, which was inaccurate. The registered managers response to our feedback was defensive, and did not demonstrate an open and approachable culture where concerns could be raised safely. We therefore were not fully assured of the culture leaders created for raising concerns without repercussion.

The service had processes in place such as a whistle blowing policy, internal staff surveys and ‘Speak Up’ guardians. The registered manager said these functions had not been utilised by staff, so was unsure why staff had raised concerns relating to the culture of the home to inspectors during this assessment. As there were concerns regarding the culture of the home and amongst the staff team, we were not assured staff would utilise these processes to speak up.

We received mixed feedback from staff around the support they received at work. Whilst some felt well supported, others told us the culture at the service prevented them from feeling able to express concerns without the fear of repercussion. The registered manager told us they are committed to ensuring the wellbeing of the staff team is held in high regard. The registered manager spoke highly of the support they received from the provider.

Policies covering equality, diversity and inclusion were in place, and staff received training in these areas. Staff had opportunities to share their feedback and concerns both internally and externally to the service. Some staff contacted us directly to share their experience of working at The Willows, however had not approached the provider themselves. The provider had sourced English Language lessons for staff who do not speak English as a first language. Supervision and appraisal processes were in place and offered staff the opportunity to discuss concerns with their line manager.

We found concerns relating to the accuracy of audits at the service. We raised this with the registered manager, who explained that staff completing audits required further training. They later stated staff had received training, and they felt the issues we found had not been identified through their own audits due to system constraints. However, the monthly audits undertaken by the registered manager consistently stated they found audits to have been completed accurately and to a good standard. We were not assured the registered manager had sufficient oversight of the accuracy of audits being completed by staff.

Whilst audits were being undertaken, these did not reflect the concerns we found in relation to the environment and cleanliness during our site visits. The level of oversight by the registered manager was unclear, as these audits had been primarily completed by more junior staff, and were consistently scoring at full compliance. The registered manager told us they had asked staff not to report ongoing environmental concerns on audits due to system constraints. However, minutes from managers meetings stated ‘All audits were completed last week no actions outstanding’. Furthermore, the environmental issues we found had not been discussed at the Risk and Governance meetings for the service, nor reflected within the registered managers monthly overarching audit. We were therefore not assured that audits were being completed accurately.

People’s relatives gave mixed feedback about their experience of working in partnership with the service. One relative told us [Registered manager] as a leader talks but doesn’t get things done. Lots of things, talk about, not get done’. Another relative also told us things do not always change in response to feedback. Other relatives spoke positively about working in partnership with the service. For example, another relative told us ‘We make suggestions, and they listen.’

Most staff we spoke with felt positive about how the service works in partnership with people, their relatives and other services. The registered manager told us they held partnership working in high regard and had built strong relationships with people’s relatives and other services.

We did not receive feedback from partners specific to this quality statement. However, we saw evidence of positive working relationships which benefitted people living at the service.

Processes to monitor and encourage partnership working were in place. Meetings with people and their relatives were regularly held, and individual meetings were arranged as required. Minutes of relative’s meetings demonstrated that people’s relatives were kept up to date with changes at the service. For example, when a new electronic care planning system was introduced, this was demonstrated to relatives so they were able to access it with ease.

Some staff told us they felt incidents of a serious nature had not been learnt from. The process for sharing and reflecting on incidents was unclear. Some staff told us this happened in handover, however others said handover was only very brief. Team meeting minutes did not reflect the sharing of lessons learnt, nor did they promote reflective practice. Individual staff supervisions were more in depth, and staff spoke highly of these. The registered manager said they discussed incidents at risk and governance meetings, however these minutes were not shared routinely with staff.

Processes for learning and improving from incidents were not always effective. There had been a recent incident where a person had swallowed a razorblade. In response to this, the service told us they had investigated and taken action to reduce risk. However, during our site visit we found further examples of people having access to risk items who were at risk of harm from them. This included gloves and razors for a person at risk of swallowing balloons and razor blades, and trailing wires for a person at risk of harming themselves. We were not assured the service was learning from incidents to reduce future risk.