The Willow

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

Some improvements had been made since the previous inspection, including improved correspondence by the provider with external agencies and stakeholders. Attempts had been made to streamline records and data management systems, with improvements ongoing. A learning culture was developing at The Willow, and there were processes in place to ensure learning for staff and changes to practice if incidents did occur. However, leaders did not have sufficient governance systems and oversight of certain aspects of management responsibilities. We found unclear governance and accountability arrangements within the leadership and management team. Policies and procedures were not all in line with relevant frameworks, legislation and guidance. A recently appointed manager was knowledgeable about issues and priorities for the quality of services, including plans to apply to become a registered children’s home. Although not embedded at the time of our assessment, there was a commitment from management staff and plans for high-quality leadership to be sustained through safe and effective recruitment and succession planning. You can find more details of our concerns in the evidence category findings below. We will be following up on our concerns and recommendations to ensure they have been put right by the provider.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders were re-designing the service, and during our assessment, the vision and strategy for the ongoing developments to the service were in the early stages and had not yet been developed through a structured planning process.

During our assessment, we found that staff and leaders were starting to develop a positive culture that promoted trust and understanding between them and people using the service and is focused on learning and improvement.

A recently appointed manager was knowledgeable about issues and priorities for the quality of services and could access appropriate support and development in their role. We saw an improvement in care planning and improved aspirations for documentation as a result of the recent management appointment. Although not embedded at the time of our assessment, there was a commitment from management staff and plans for high-quality leadership to be sustained through safe and effective recruitment and succession planning. Staff and leaders worked in partnership with key organisations to support care provision, service development and joined-up care. There had been an improvement by the provider with communication to relevant stakeholders. However, leaders were not sufficiently transparent when communicating with all relevant external stakeholders and agencies, for example with regards to applying to register with other regulatory bodies. We recommend as a priority that this is reviewed by the provider.

Some staff and leaders actively promoted staff empowerment to drive improvement. Most staff members employed by the provider felt they could raise concerns. However, not all staff were confident that their voices would be heard or that appraisals were the appropriate forum for this to take place.

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.

Staff told us that The Willow was undergoing changes to its service model, which included changes in management structure and leadership. Therefore, understanding of roles and responsibilities was still in development at the time of our assessment. We saw that arrangements for records and data management systems were improved from previous inspections, but the provider continued to have unclear document storage solutions and a limited ability to retrieve documentation when required. However, we saw a commitment and plan to improve this with new systems due to be implemented.

However, there were unclear governance and accountability arrangements, which, at the time of our assessment were in the process of being reviewed. Leaders have not always communicated clearly regarding future planning on changes to key roles and the need for registration with other regulatory bodies . We noted some concerns with relation to the provider’s policies. Although many of them had been amended and updated prior to our assessment, we found that leaders did not consistently implement relevant or mandatory quality frameworks within these policies. This was especially in relation to the CCTV policy reflecting understanding of capacity and consent of children and young people under 18. Other policies were insufficient, including the medicines policy, with no reference to PRN medication. We recommend as a priority that the providers policies were reviewed prior to new service-users being admitted.

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.

Most staff we received feedback from spoke positively about the access to training and learning facilitated by the provider. Staff received additional training appropriate and relevant to their role, including recent access to Oliver McGowan and autism training, delivered in-house by an accredited trainer.

We saw processes to ensure that learning happens when things go wrong. Most staff employed by the provider felt this was a supportive process, although others felt appraisals were not optimum for reflection.