Watery Lane Cottage

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

A review of accidents and incidents found incidents and accidents had been recorded. However, we identified the systems in place were not fully embedded and there was a lack of documentation to formally record incidents and accidents.

However, there was evidence that incidents were being discussed with staff and used as opportunities to promote learning and improve practice.

Leaders said they reviewed incidents and reported through the organisation’s reporting system and carried out spot checks to gather further information, including reviewing risk management arrangements and identifying any emerging themes or trends. This helped support oversight of safety and informed actions to improve the quality of care needed.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People’s needs upon admission were clearly communicated to staff. People had hospital passports in place which clearly communicated people’s needs, and the support required should an overnight stay in hospital be required.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff demonstrated an awareness of safeguarding and the actions they would take if they had any safeguarding concerns, including raising the concern with their manager. There was a safeguarding policy in place and staff have completed safeguarding training.

Up until June 2026, people could only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that staff and management worked within the MCA. DoLS authorisations were appropriately applied for and overseen. People were not subject to unlawful or excessive restrictions. They had choice, control and freedom over their lives.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Relatives told us they were involved in developing care plans and risk assessments and felt their views were listened to and acted upon. Risks to people’s health, safety and wellbeing had been assessed, and care plans contained detailed guidance for staff on how to provide safe and consistent support.

Staff demonstrated a good understanding of the risks people faced, and the actions required to reduce the likelihood of harm. For example, one staff member clearly explained how they would support a person during an epileptic seizure to keep them safe, monitor their wellbeing and minimise the risk of injury.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

We found some actions identified through a fire risk assessment, including high- priority works relating to fire doors, had not been completed in a timely way. This increased the risk of harm to people and staff in the event of a fire. During the assessment, the provider responded promptly to address the concerns we identified and took steps to ensure the required actions were completed.

Discussions about fire safety with staff identified concerns about emergency evacuation arrangements. Staff told us evacuation times could vary depending on the experience and skills of staff on duty at the time. Some staff told us they were concerned that, with only 1 staff member on a sleep-in shift, people may not be evacuated as quickly as during fire drills. This meant the provider could not be fully assured that people could be evacuated safely within the expected timescales.

The provider told us they were undertaking further assessments of staff responses to emergency evacuations and would review the findings to ensure evacuation arrangements remained safe and effective. The provider also said they had contacted the fire safety officer for advice on this matter.

One relative told us their family member’s room appeared outdated and would benefit from a refurbishment. They also raised concerns about the suitability of their relative’s mattress for their health and continence needs. The provider addressed this concern had confirmed the person has been provided with a suitable mattress.

Feedback from relatives about the environment was generally positive, they described bedrooms as clean, warm, safe and personalised to people’s preferences.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,

supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Staff told us there were challenges on some shifts when 2 agency staff members were working alongside 1 permanent member of staff. Staff explained this was particularly difficult when agency staff were not trained in BSL. This could place additional pressure on permanent staff to support communication and ensure people’s needs were met safely and effectively.

Staff had completed the provider’s mandatory training and told us they received training relevant to their roles, including training on learning disability and autism. However, some deaf staff told us they experienced delays in accessing face-face training because BSL interpreters were not always available when needed. This meant staff did not always have equal access to training and development opportunities.

The provider ensured new staff were recruited safely including obtaining references and Disclosure and Barring (DBS) checks.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The home was clean and free from malodour. Staff had received training in infection prevention and control (IPC) and were observed to be using good infection control practice.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

We observed that medicines were given to people in a person-centred and caring way. We found medicines were stored securely and staff managed medicines safely.

Care plans contained information on how residents liked to take their medicines. Protocols were in place to support the use of “when required medicines”. Information was available in care plans to support staff in managing medicines for complex health conditions such as diabetes and epilepsy.

Staff worked closely with the GP practice to resolve medicines issues in a timely manner and to ensure people received medicines reviews. Policies and procedures were in place relating to medicines and we observed staff following these during our visit. Although medicines audits were not completed in May and June 2026, recent internal and local authority audits had identified areas for improvement, and the provider had taken action to address these. However subsequent medicines audits had taken place which showed the provider was working towards strengthening governance in this area. Staff told us they completed mandatory medicines management training and annual competency.