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

Well-led – this means we looked for evidence that leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment this key question was rated inadequate. At this assessment the key question remains inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

At our last assessment we found a breach of regulation relating to governance. We served a warning notice relating to this breach. At this assessment we have found the provider had not made the necessary improvements and they remain in breach of Regulation 17: Good governance, as well as repeated breaches relating to person centred care and safe care and treatment.

This service scored 29 (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 did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

There was a lack of shared vision within the service to make improvements to ensure people using the service had good outcomes and were provided with safe care at all times. There had not been enough improvements made in the provision of care and support provided since the previous assessment. There remained shortfalls in the service provided, and records were contradictory and inaccurate and did not effectively guide staff in meeting people’s needs.

Two staff told us about how the workplace was not a happy one, with a divide amongst staff, with reference referred to bullying. We saw minutes of a staff meeting in November 2024 where staff had been advised of the expectations of staff demonstrating respect with each other. Two staff told us they were happy working in the service. A member of staff told us they felt the manager listened when they had concerns, but did not feel it was acted on. Whilst staff were more positive about the new manager since our last assessment, we heard that the regular changes which had taken place in the leadership of the service did not contribute to a positive working culture.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation.

The provider did not have effective systems to assess, monitor and improve the quality and safety of the service provided and to mitigate the risks relating to the health, safety and welfare of service users.

There was a lack of stable management to drive improvement and to sustain any improvements made. Since registration, there had been 6 registered managers in post, the length of time for these registered managers being registered ranged from 4 months and 14 months. We were also aware of a further 3 managers who had not been registered. The current manager was not yet registered but told us they had submitted their application. This contributed to instability at The Willows and any improvements made were not sustained over time. We received some comments from service user’s relatives about the changes of management, which caused them concern. One stated, “The current manager is very efficient but I fear the service will decline again when [manager] moves on. I think [manager] is a ‘Troubleshooter’ who is brought in when homes are failing.”

People did not feel they could speak up and that their voice would be heard.

Staff were encouraged to raise concerns about the service internally, the meeting minutes from November 2024 reassured staff that their voices would be heard and their concerns acted on. There had been a communication book introduced where staff could raise comments to one of the service’s directors. However, this was kept in the main entrance hall to the service, and did not ensure confidentiality and privacy of the staff who wished to write in it. The minutes also stated staff should not raise concerns direct to Care Quality Commission or outside of The Willows. This is a risk of developing a closed culture and did not support continually evaluating and improving the service through encouraging feedback and the raising of concerns through a variety of mechanisms. We wrote to the staff team to ask for their feedback about the service, whilst we received feedback from ancillary staff, we only received feedback from 1 member of the care team. We raised this with the manager, whilst staff were not required to respond, it was not clear why only 1 of the staff team had. The manager told us he would speak with staff to reassure them. One of the directors told us the message in the minutes had been misunderstood by us and the response for staff not responding to us was because they were, “Scared.” We were not assured that the leadership supported staff to understand the roles of external professionals.

Staff surveys had been undertaken in July 2024. The summary of these completed by leaders documented responses to any comments made, it did not analyse where there had been low scores given to any questions. There had been a missed opportunity to identify if there were trends in responses and actions taken to address them and improve staff’s experiences.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

We had been told about a staff divide by the manager and how they were working to improve this by introducing a mentor/buddy system. During the assessment feedback the manager told us they had been researching available cultural sessions in the community. None of these had yet been implemented, despite us discussing it at our last assessment. There had been no consideration of creative ways of bringing the staff team together in a positive way.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider continued to not have effective governance systems in place to identify and drive improvements at the service. Audits were completed by leaders but failed to identify shortfalls we found during our assessment. From the governance records we viewed, we saw that quality monitoring audits were not robust nor used meaningfully. For example, a weight audit undertaken in November 2024, stated 4 out of 46 service users had lost weight. However, it was not clear how this had been calculated given our analysis showed there were more than 4 people who had lost weight each month. A kitchen audit in November 2024 was scored at 100% compliance, however it had not identified information about service users who were at risk of choking not being provided to the catering staff.

There was a lack of analysis and lessons learned to support leaders to continuously improve. Whilst there was analysis for accidents and incidents, we were not assured these had taken into account incidents noted in daily records, and there were no lessons learned documents. There was no analysis of complaints and safeguarding to identify any trends and actions taken across the service to learn lessons and reduce future risks, which were shared with all staff members. The manager told us they planned to introduce formal documentation of lessons learned, but this had not been implemented, despite ample opportunity to put this in place since our last assessment.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

Prior to our assessment we received information of concern from the local authority, that improvements that had been made in 2024 following our assessment, had not been sustained. Commissioners had suspended their contract to place people in the service since 2024 due to concerns about the service being provided. The service had failed to make enough improvement and sustain them since our last assessment, despite support being provided by the local authority.

Whilst the service worked in collaboration with other stakeholders, they did not always maintain robust records, for example details of treatment received by people and guidance received, for example from health professionals in care records. This meant it was difficult to audit and fully understand the care and treatment people had received, or when professionals made recommendations. This placed people at risk.

Whilst there were meetings held for relatives; they did not all feel they were given the opportunities to influence how the service was delivered. Some relatives told us they had not been asked for feedback on the service their family members received. We reviewed the summaries of satisfaction questionnaires completed by people who used the service and their representatives undertaken in July 2024. Comments were made where individuals had raised concerns, but there was a lack of analysis of the scores received. Where low satisfaction scores had been provided to any questions, there was no documented recognition of this and no indication of any actions taken if there were any common themes. This demonstrated whilst feedback had been sought, the opportunity had been missed to use feedback, to make improvements to enhance individual’s experiences.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The service could not demonstrate they had a good understanding of how to independently identify shortfalls and make improvements which were sustained over time. At this assessment we found whilst some improvements had been made, the provider had failed to make the necessary action to learn from the previous rating and breaches of regulation and remained in breach of 3 regulations. This did not demonstrate learning, improvement and innovation.

Despite staff being provided in training in the electronic system to record the daily care provided to people, this had not been effective because there were contradictions, dual reporting and concerns throughout. For example, a person’s daily notes identified they had refused to have their continence pad changed, however, their prescribed cream was applied. These did not demonstrate people were provided with a service which met their needs and preferences and kept them safe from harm.

The service had failed to involve people, their representatives, and staff in developing and improving the service. Despite being given opportunities for improvement, the service had not used these to ensure people’s experiences and care provision was safe and the high quality they deserved.