Willow Brook

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

We identified a continued breach of the legal regulations in relation to good governance. The provider still did not have effective systems in place to assess, monitor and improve the quality and safety of the service. Systems to assess and monitor medicines, infection prevention and control and the implementation of the MCA had not identified or effectively addressed the concerns found during the assessment. Not all staff felt they could speak openly and did not always feel their voices were heard. Staff had received training in equality and diversity, and we saw evidence of workforce equality being promoted by the manager. Professionals visiting the home felt the service was improving and said people had access to healthcare support if required. The leaders acknowledged the feedback given by the inspectors and took some action during the assessment to start addressing the concerns found.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Not all staff were able to fully describe the direction and vision of the service. Staff told us they were confident the organisation promoted compassionate care. However, they did not always describe an open culture that made staff feel valued and heard. The manager was open about the action they had taken and continued to take to improve staff culture. This included promoting the values of the provider.

We saw evidence values had been discussed during supervision sessions. Staff interview questions were value based to ensure right from the start staff shared the provider’s values.

We received mixed feedback from staff regarding the leadership. Most staff felt the manager was approachable and worked alongside staff as a role model. Some said they felt leaders did not always value their feedback and they would welcome more positive feedback. The manager felt supported in their role by the provider. A care director provided regular support to the service.

The manager had submitted an application to become a registered manager with the commission and was waiting for a register manager assessment. Processes and policies were not always followed and implemented by leaders. For example, the service did not always follow the provider’s policy in relation to the MCA and infection prevention and control. Leaders had received appropriate training to carry out their roles.

Some staff reported that they did not always feel able to raise concerns with leaders, this was because they felt action would not always be taken in response to their concerns. The manager told us, “We have different forums, team meetings, supervisions, we give staff opportunities to raise concerns.”

The provider had an up-to-date whistleblowing policy in place to ensure staff who raised concerns were protected. The manager told us they did not have a freedom to speak up lead. During our assessment, they implemented a freedom to speak up folder. They also shared with us a new supervision template which included, freedom to speak up, equality, diversity and inclusion and respect and dignity. Time was needed for these new systems to become effective in supporting staff to speak up with confidence.

Most of the staff we spoke with felt there was no discrimination at the service and felt it was an inclusive place to work. The manager explained the importance of being open and supportive to staff and people they supported and gave examples of how staff were supported through reasonable adjustments.

Staff had received training in equality and diversity Policies and procedures were in place to support the fair and equitable treatment of staff who worked in the service.

Staff knew how to access the provider’s policies to support them in their roles. Leaders were not always able to demonstrate an understanding of key risk and improvements still needed following our last inspection or provide assurances on how improvements were being made. Staff did not always feel their feedback on service improvements were actively sought.

The provider’s governance processes were still not used effectively to monitor the quality of the service, manage risks and drive improvement. This placed people at risk of harm. There were several systems in place to help the manager to ensure the service improved and develop. This included audits and checks. The manager had also developed an action plan following the last inspection; however these had not been effective in addressing all the concerns we found at our last inspection. We found continued concerns in relation to infection prevention and control, care records and implementation of the MCA which had not been identified through the provider’s quality monitoring systems. The manager had worked with the local authority to make improvements in care plans and risk assessments. There was no formal system in place to seek and act on people and professional’s views or to review and monitor the relevance and quality of activities offered.

People were not able to give us any feedback about partnerships and communities.

The manager told us about the professionals they worked in partnership with including social workers and healthcare professionals.

Professionals told us staff were motivated to work closely with all the relevant professionals. They felt the service was working at ensuring they knew which team to contact for what.

We saw evidence of positive partnership working in documentation of care review meetings, health review meetings and of staff contacting medical professionals for advice if needed. People’s care plans were updated accordingly. Some care plans and risk assessments had been co-written with professionals.

Staff felt there was a focus on making improvements in the service. However, staff did not feel they were always given opportunities when things went wrong to reflect what went wrong and what could be done to support changes and improvements. The manager understood the importance of learning and improving their service. The manager used the assessment as an opportunity to further improve the service.

Leaders were working with stakeholders to develop learning and make improvements. Following our previous inspection learning had been embedded in relation to incident management and notification, safeguarding processes and people’s risk assessments. However, learning had not taken place in all areas identified as concerns in our previous inspection.