Willow Grange Nursing 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

At the time of our assessment the regional manager was providing management and oversight of the service, whilst they were awaiting the start date of a newly recruited manager. Improvements had been made and there was now a robust governance structure in place to review the quality and safety of care delivery. There was a commitment to continuous improvement. Staff confirmed that improvements had been made to the service, including an increase in staffing levels and to address previous breaches of regulation. However, people felt that their views were not listened to, and they were not involved in their care planning and the development of the service. The management team had plans in place to rectify this and ensure new processes were in place to act upon feedback given by people and relatives. We assessed 4 quality statements in the well-led key question and found areas of good practice. The scores for these areas have been combined with scores based on the rating from the last inspection, which was requires improvement. The assessment of these areas indicated areas of good practice since the last inspection, our rating for the key question has improved to good.

This service scored 64 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

The management team had a good understanding of people’s care needs and oversight of the service they managed. The home was currently managed by the regional manager who knew the service well and had the necessary knowledge and experience to lead the staff team effectively. A new manager was appointed and expected to start working for the provider in May 2024. The provider had a plan on how the new manager was going to be supported to develop in their role in order to make improvements at the service.

Systems were in place to ensure good communication and delegation of tasks between the staff team. Daily meetings for staff at all levels were carried out to share and discuss information about the business of the day. Tasks were delegated to the staff team who appeared competent in their roles. Staff were empowered to take responsibilities, such as making arrangements and leading meetings with external agencies.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Governance systems were in place to review the quality and safety of service delivery. This included a range of quality checks in relation to people’s care plans, complaints, medicines, equipment and incidents. Where these processes identified that improvements were required, prompt action was taken to address these.

The manager of the service told us they had an open-door policy which encouraged openness and transparency with the staff team. There was an internal inspection programme which underpinned their governance structure and this process was used to drive improvements. Staff understood their role and responsibilities and how to apply them.  A staff member told us, "Our responsibility is to make sure people are safe at all times and happy. We get allocated in the morning who we need to support. We help each other.”

Staff felt listened and involved in making decisions about how the service can be improved for people to achieve the best outcomes possible. Comments included, “Yes, we raised concerns about staffing, and these were addressed. We go to regular meetings, and I feel able to speak up and share my views” and “The things are easier now than before. Changes had been made as suggested to the managers. We have more staff now. It makes work easier.” Staff worked in partnership with healthcare professionals to support people’s well-being. Staff’s comments included, “We see the dietician and physio. We get feedback from them, and we talk how best to help residents. We had an assessor for the standing hoist so we could use it correctly” and “We had [healthcare professionals] coming in and going through the documentation which was very helpful because we made changes in the way we record things.”

Systems in place had not always supported people’s feedback about the service delivery. We viewed the results of the surveys completed by people in 2023 and found that actions were not always specific to address the issues identified such as lack of stimulation. This was discussed with the regional manager who told us that surveys for 2024 were due to be returned and that the service will focus on actions necessary to address people’s most recent feedback. The regional manager told us that with the new manager in post the service planned to introduce a keyworker system and internal review meetings with people to encourage and support people to share their views about the service and their care delivery.

People were confident to raise their concerns. However, most people felt they were not well supported to review their care needs so they could ensure the service worked well for them. Comments included, “They don’t ask me if I’m happy with my care, but if I wasn’t, I’d say something”, “They don’t really ask you if you are happy with things” and “I haven’t been asked about my care, no review.”

Healthcare professionals working with the service told us there were good working relationships. Staff communicated with them regularly about people’s health and welfare, and followed any advice given to ensure people received the level of care and support they required.

Systems were in place to capture learning to support continuous improvement. Action plans were put in place after the last CQC inspection and local authority’s visit aimed to implement change in practice. This was in relation to staff support and care records. Team meetings took place to update staff on the important matters and also to agree on actions necessary concerning people's care.

Staff told us there was a commitment to continuous learning and improvement. Staff’s suggestions to make improvements to the service were incorporated into service delivery. Staff were able to tell us about a number of the improvements already made at the service. This included an increase in staffing, addressing previous breaches of regulation identified at their previous CQC assessment and taking prompt action in response to feedback provided at this assessment.