Willows Lodge 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

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. We assessed a total of 4 quality statements from this key question. We have combined the scores for these areas with scores based on the rating from the last inspection, which was requires improvement. At this assessment this key question has remained requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

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.

A member of staff told us, "The manager is very approachable. They are doing their best." However, another member of staff told us, "You need to be a manager to manage. We often don't know what is happening in the home at any given time. There is no further information given. Anything that happens in the home, we should be made aware of. "

The management have been working closely alongside the local authority. Feedback from a health professional stated, “The manager of the service does communicate effectively with us, and we have been able to build a good working relationship. The previous compliance visit for Willows Lodge had an overall rating of requires improvement. Since then, the manager has put in place and completed an action plan for areas where they were underachieving and are keen to keep up with improvements already made.” The day to day running of the service was managed by the registered manager. There was a clear staffing structure in place and the registered manager had been receiving support from the operations manager on a regular basis. The registered manager told us they have appointed a deputy manager to assist with the overall running of the service. The registered manager told us, "It has been very difficult without a deputy manager. Just when I thought things were starting to settle, I feel like we've had to start again. I am getting a lot of support now which has been very helpful." The registered manager recognised improvements were needed to ensure governance and leadership was more robust and effective in managing the day-to-day quality assurance of the service. This would ensure all actions identified in quality audits were followed through and sustainability was embedded into the service.

Staff told us they had supervisions, but these were not completed regularly. A staff member told us, “I can’t remember the last time I had one, but I have had a supervision. It would be useful to regularly meet with seniors to discuss any concerns we have on a one-to-one basis.” Another member of staff told us, "I’ve supposed to had one I think they’re every 6 months. I was supposed to have one 6 months ago I got fobbed off, I’m sure one supervision was signed and I don’t remember having it. I was told I’m due another supervision now, I say I didn’t get the first one, I’m sure the last one I remember having was with the previous manager.” Staff told us they had an induction when they first started, and this prepared them for their role. Staff told us they felt confident to raise any issues with the registered manager and felt these would be addressed. A staff member told us, “The manager is extremely approachable and I can talk to them about anything. We have all built up good relationships and the manager has an open door policy.” Another staff member told us, “We do have daily flash meetings and the manager shares information with us, we also have regular staff meetings which is a good time to sit and discuss any issues we might have.”

The registered manager had policy and processes for staff to follow on ‘whistle blowing’. Staff meetings were being held regularly. We reviewed minutes and saw they included information about the service as well as reminders about training, staff rota’s, safeguarding and PPE. However, there were no 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 sent surveys to people using the service to gather feedback about the service and discussed feedback with people who used the service. However, there was no formal record of discussions that took place following the survey. The registered manager told us they carried out regular resident meetings and we saw evidence of this. However, results were not always analysed for themes or trends and there was no action plan put in place to address issues raised.

We received variable feedback from staff in relation to management. A member of staff told us, "The manager is very approachable and if you have a problem their door is always open. I think staff morale can be a bit low but that's because there's just not enough of us." Another member of staff told us, "The staff morale currently is extremely low. You need to be a manager to manage." Another member of staff told us, "I think there could be more staff. We often discuss this with the manager and they are dealing with it."

The quality assurance and governance arrangements in place were not always effective in identifying shortfalls at the service. Risks to people’s safety and wellbeing were not always being recorded, monitored, and managed effectively. Although there was systems in place to ensure staff recruitment files and inductions were audited, these were ineffective to ensure staff files were in line with regulatory requirements. This meant effective auditing arrangements were not in place to assess, monitor and improve the quality and safety of the service provided and lessons learned. There was no formal record for how the registered manager learnt from lessons following incidents. Effective systems to monitor and improve the quality of the service were not in place. This was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The management have been working closely alongside the local authority. Feedback from a health professional stated, “The manager of the service does communicate effectively with us, and we have been able to build a good working relationship. The previous compliance visit for Willows Lodge had an overall rating of requires improvement. Since then, the manager has put in place and completed an action plan for areas where they were underachieving and are keen to keep up with improvements already made. At times we have felt the manager needs more support from their directors within the company.” Another health professional told us, “We advised that staffing levels were low and there was a need to increase the staffing levels on the first and second floors. The first floor had a staff increase earlier this year however, still in need of a clinical lead. The second floor more recently had 1 extra staff early shift put in place to maintain safe staffing levels. During our visits we have seen staff having good rapport with individuals they are supporting however, staff morale was very low due them feeling understaffed. This has been improving more recently.”

The management have been working with the local authority to aid improvements at the service. This process is on-going and full engagement is required from the provider to ensure improvements are made. The registered manager had developed good relationships with the local GP, district nurses and mental health professionals. Staff were aware of the importance of working alongside other agencies to meet people's needs and liaised with other healthcare professionals such as the GP and pharmacy when required. However, a health professional recently raised concerns in relation to a person not receiving the correct treatment from a member of staff in relation to a pressure wound. The pressure wound was identified by a relative and not a member of staff.