Willows Lodge Care Home

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. The provider was previously in breach of the legal regulation in relation to governance. Improvements were found at this assessment and the provider was no longer in breach of this regulation.

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 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 management team had evaluated issues at the service and was driving improvements. There was a culture of support being provided to the senior team and care staff working at the service. The registered manager was being consistently supported by the provider and regional manager to action the changes and drive improvements at the service. The management had clear values and were aware of the direction they wanted to take. The registered manager had developed a listening culture where staff can feel they are available for them to talk to.

The provider 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 clear about their roles and had the skills, knowledge and experience to perform their job. The registered manager felt supported by the provider and regional manager who carried out regular audits and monitoring. A health professional told us, “The home manager is approachable and responsive, [manager] is always happy to work with us in relation to any concerns raised.”

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The registered manager had policy and processes for staff to follow on ‘whistle blowing’.  We reviewed both staff and clinical meeting minutes and saw they included information about the service as well as reminders about training, staff rota’s, safeguarding, incidents, infection control, weight management and PPE. There was detailed action plans completed to evidence how issues raised were to be addressed, dates to be achieved and if actions had been resolved or remained outstanding. The registered manager held a monthly residents meeting and had arranged a relatives meeting for people to share their thoughts about how the service was ran and if they had any concerns or suggestions. A staff survey had been sent out for staff to complete. The management were collating the results to analyse for any themes or trends. Management told us the survey results would be discussed at the next staff meeting.

The service valued diversity in their workforce. The provider worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. There was a policy in place to protect staff from harassment and bullying and a focus on protected characteristics under the Equality Act. The registered manager had developed an inclusive workforce and recognised the value of diversity amongst the team.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. Improvements had been made since our last assessment and the provider was no longer in breach of regulations. The registered manager worked closely alongside the regional manager and had established a number of audits which provided them with a good oversight of the service. There was also a central action plan, devised by the regional manager, in place which was being worked through. The registered manager had given staff a clear direction of their vision for the service. Staff understood their role and contribution in sustaining improvements. A health professional told us, “I have visited Willows Lodge regularly over the last year and have seen some improvements in how the service is run.”

The service understood 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. The management and staff shared the same goal to provide positive outcomes for people. The registered manager encouraged staff to discuss and share ideas for improvement and innovation.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. The management was actively supporting staff with learning and innovative ways of working at the service. Staff were encouraged to develop their skills and were supported to obtain nationally recognised qualifications. One member of staff told us, “I asked to work on the nursing floor to support and shadow the nurses. I am now waiting for my Nurses pin. I have completed lots of training here and they are always encouraging us to develop our skills. There are always opportunities for growth and development.”