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

Governance systems were in place however they could be developed to ensure robust oversight of areas such as staff deployment, record keeping, involvement and activities.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

When the registered manager was not on site, we noted the deployment of staff was not effective and roles and responsibilities appeared indistinct. The registered manager was responsive to our feedback and immediately took action to review and resolve staff deployment which improved the time staff had to engage and interact with people. Feedback from staff was positive in relation to their role and accountability. They felt well supported by both the registered manager and the nominated individual. Staff had attended training on understanding their role and worked together to meet people’s needs.

A governance policy was in place which set out the registered manager’s responsibilities in terms of auditing arrangements. However, quality assurance systems had not always been used to robustly assess the quality of the service and drive improvements. Care records were reviewed as part of ‘Resident of The Day’ processes; however, people’s involvement was not always clear. Areas for improvement had been identified during our assessment which hadn’t been identified by the provider. For example, staff deployment and the impact on meeting people’s needs and a lack of meaningful engagement and activity for some people. An action plan was in place; however, it was not dated, and it had no clear timescales for achieving actions, and it was not always clear who was accountable for action. It was evident the registered manager worked extremely hard to ensure people's safety and continuity of care and although improvements were required to develop governance procedures there was no evidence of any negative impact on people.