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 Willows has had a history of non-compliance with the regulations, and a pattern of making improvements and then failing to sustain them. There has been a high turnover and frequent change of manager which has not supported the embedding and sustaining of improvements. Governance systems were not robust. This assessment identified six breaches of regulation as systems and processes were either not in place, or not robust enough, to ensure people's care needs were identified and people received safe care and treatment. The provider's oversight and monitoring systems and processes were not robust and failed to appropriately manage risks to people. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Several staff members told us they have raised concerns with the management team about the staffing levels and they have not been listened and continuously told there are enough staff and in some cases overstaffed. In addition, some staff told us they did not feel listened to about concerns and are often told to go to different members of the management team, so their concerns remain unresolved. In addition, some care staff told us heads of other departments told them what to do, which they found confusing. We received feedback that the culture in the service was not a happy one for staff to work in, where individual staff were talked about, and staff turned against each other. Despite our concerns about the staffing levels, we had received feedback from a staff member who told us that if staff did not moan so much about the staffing levels, they would have more time to do some work. This was clearly not our findings, and where staff were raising concerns, it was because they were worried that people were not receiving the person centred care they required. We received concerns of bullying between staff members and cliques of staff being formed.

A relative told us there were meetings where they could attend and raise concerns. However, they had missed the last meeting, they had said they would appreciate an email reminder, staff had told them the meeting details were posted in the entrance to the service. We saw the minutes from a relative meeting held in March 2024, which kept them updated with changes in the service, in addition relatives were told there had been concerns about the food provision which they were working on to improve. We did not see any minutes from meetings held for people who used the service, a staff member told us there had been one held in November 2023. There had not been recent surveys for people and relatives about the service provided. However, we did see in the entrance to the service a board which stated actions taken as a result of feedback, but this did not have a date of when feedback had been received. We saw very little feedback received from people using the service, including in their care records, about the care they were provided with. The local authority safeguarding team had also received concerns about the service and visited as part of their investigations. They had also found shortfalls in the care and support provided and regarding staffing levels. The local authority was so concerned about the findings they suspended any commissioned new admissions until improvements were made.

We received mixed views about if people felt the service was well-led. Some people knew who the manager was, and some told us they did not. We also received mixed feedback from staff, some staff told us the registered manager was not a visible presence in the service and when they had approached them, they were directed to speak with the deputy managers, who then directed them to speak with the registered manager. Some staff told us if they had concerns, they would go directly to their line manager, in the first instance, and not the registered manager, because they felt the registered manager did not listen to them.

The service had multiple registered managers in a short period of time. This was identified in previous inspections. Our inspection report published in September 2022 we had identified at each inspection there had been a different manager working in the service, which increased the instability of the service. In our inspection report published in June 2021, we also identified we were concerned about the changes in management of the service and how improvements were not always sustained. This was the sixth registered manager in post since 2018, in addition there had been another 2 managers who had not registered with us. The current registered manager had been registered with us on 25 March 2024.

The registered manager told us they had an open-door policy and they were trying to encourage staff to speak openly about their concerns in the service. However, feedback from some staff identified that the registered manager was not visible, and they did not feel listened to when they raised concerns, for example about the staffing levels. Staff told us they were aware of the whistleblowing procedures in place and understood when to report concerns.

There was a Duty of Candour policy and procedure in place. There were policies and procedures in place relating to freedom to speak up and whistleblowing, which explained staff and provider responsibilities. The extensive feedback we received, however, identified that staff felt unable to speak up and raise their concerns about the quality of care people received.

We received feedback that the culture in the service was not a happy one for staff to work in, where individual staff didn’t feel supported and didn’t always work professionally with one another. The management team told us a director of the service held quarterly meetings with the staff who were sponsored to work in the UK.

There was a lack of one to one supervision meetings for staff to provide them with a forum to raise any concerns about the service. This would give the management team the opportunity to explore if there were any concerns relating to equality and diversity in the staff team. The registered manager told us they had a plan in place to provide these going forward. There were policies and procedures in place for equality and diversity and anti-bullying.

Improvements which had been made were not always sustained. The chief operating officer told us they visited the service, undertook checks and audits and spoke with staff as part of the governance processes. The chief operating officer told us the overarching improvement plan was updated following feedback received from the local authority and would be further added to following our feedback. We found the improvement plan was mostly reliant on feedback from external agencies such as the local authority safeguarding team as opposed to the provider identifying concerns that needed addressing. The registered manager told us they walked around the service to monitor what was happening, in addition the daily meetings with head of departments assisted them to identify and discuss any emerging issues. Despite this, the registered manager failed to identify the concerns we found at this assessment. A call bell audit was undertaken by the management team in February 2024 rated 75%. It was not clear what was checked and how the result was identified. The registered manager told us, “The call policy states that call bells should be answered in a timely manner. The call bell system has been set to go to emergency if it is not answered within 15 minutes. In this audit the staff assistance bell was pressed as was not answered after 5 minutes – this was on the middle floor of the home. Staff on this floor were spoken to immediately about the reasons why the call bell was not answered, and a discussion was had on the importance of answering call bells in a timely manner.”

We were concerned that the governance systems in place had not identified all of the concerns we had identified during our assessment. This included the lack of stimulation, people’s appearance and personal care provision and how staffing levels were not sufficient to meet people’s needs. This was identified during our visits prior to reviewing any records, the management team had missed opportunities to walk around the service and identify these concerns, and to listen to the concerns staff had raised. The registered manager sent us records of audits completed, which included fire safety checks, and environmental checks. We also received a mealtime experience audit completed in March 2023 which was rated as 100%, a care plan audit was completed January 2024 where 2 care plans were checked, this was rated 98.33%. We were concerned that the audits had not picked up the issues we had identified during the assessment. We were provided with an overarching improvement plan, which identified required actions for improvement and when they had been completed. The majority of the actions related to improvements needed in the environment (18). 4 actions were to recruit to the activity, catering, deputy and receptionist staff roles, 1 to meet quarterly with sponsored staff and to allocate a new office for the registered manager. There were no items on the plan which directly identified improvements to be made in people’s care provision and experience.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

There had been widespread failures to ensure compliance with the regulations despite the management team telling us there were processes to ensure that learning happens when things go wrong, and from examples of good practice. The registered manager told us they were in the process of ensuring staff training was up to date and they would all be provided with one to one supervision meetings, however, these shortfalls had developed over a number of months and meant staff were working without the appropriate training and support. The management team were responsive to our feedback and gave assurances improvements would be made.

We were concerned that there were gaps in staff training, which we were told was going to be improved, however, at the time of our assessment there were considerable gaps and therefore there was a risk staff were not appropriately trained to deliver safe care. This placed people at risk of receiving inappropriate care. The management team had missed opportunities to identify and document how they had learned from, for example, accidents and incidents, safeguarding and concerns raised. The provider had failed to learn lessons from previous inspections where shortfalls had been identified and there had been breaches of the Regulations, For example in relation to staffing levels. Improvements made had not been sustained over time and at this inspection we have, again, identified breaches of the Regulations. We were not assured the governance systems in place were robust enough to ensure improvements made were sustained over time to ensure people were always provided with high quality and safe care.