Watery Lane Cottage

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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has remained good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Leaders said they regularly discussed the organisations values and expected behaviours with staff through supervision, team meetings and observations of practice. This helped staff understand their roles and responsibilities and encouraged care and support to be delivered in line with the provider’s values.

Leaders also described how they routinely monitored the culture within the service to identify any risks of a closed culture developing.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

At the time of our assessment a new registered manager had been appointed, before this, the service had experienced a period without consistent leadership. However, the provider had maintained management oversight to support the day-to-day running of the service. Staff told us there had been a number of changes in management over the recent years and said this had been challenging at times because different managers had introduced different approaches and expectations.

However, staff spoke positively about the registered manager and told us they were hopeful that consistent leadership would bring stability and improvements to the service. The registered manager told us they had received significant support from senior leaders as part of their induction. They had also started learning BSL to help improve communication with people using the service and with deaf members of staff which demonstrated a commitment to creating a more inclusive environment.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider had systems in place to gather feedback from people, relatives and staff. However, during the period without a registered manager, these processes were not used effectively, resulting in some feedback not being reviewed or acted upon for several months.

However, we saw policies and procedures were in place to support both people using the service and staff in raising concerns or sharing their views. Staff told us they could feedback concerns to the registered manager. The registered manager described how they maintained an open and approachable culture by listening to feedback and responding to issues raised. For example, when staff identified the need for a new mattress for a person the registered manager arranged for this to be purchased promptly. Staff were also given regular opportunities to feedback views through team meetings, including providing feedback on new systems such as the shift plan document.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Policies and procedures were in place to support staff in their roles, and leaders made reasonable adjustments to help staff perform their duties effectively. For example, deaf staff were provided with assistive technology to alert them when people required support or when the doorbell sounded. This helped staff carry out their roles safely and effectively and promoted greater accessibility in the workplace.

The registered manager told us they had access to support from an internal BSL interpreter, including for staff meetings and supervisions. However, some staff said they did not always have timely access through the government’s ‘Access to Work’ scheme, [This scheme can provide practical support, such as sign language interpreters, to help deaf people carry communicate effectively and carry out their role]. including access to BSL interpreters for training sessions. As a result, deaf staff did not always have the same opportunities to access training and development as their colleagues.

The provider did not always have clear responsibilities, roles, systems of accountability and good governance. They did not always use these to manage and deliver good quality, sustainable care, treatment and support. They did not always act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Leadership and governance arrangements were not always effective in ensuring delivery of high-quality, person-centred care. While the provider had identified areas for improvement and was actively responding to concerns, the auditing systems had not consistently identified and addressed issues identified during this assessment. For example, outstanding high-risk issues regarding the fire risk assessment.

Leaders demonstrated a good understanding of the service’s strengths and the areas that required further development. An action plan was in place to drive improvement and support the ongoing development of the service. Issues identified during a recent local authority review had been addressed, showing that leaders responded appropriately to feedback and scrutiny. There was also evidence of regular oversight and support from senior leaders and the provider’s quality improvement team.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff worked effectively with a range of health and social care professionals to meet people’s needs including specialist nurses, GP’s and social workers. Leaders told us they made referrals to relevant health and care professionals when needed and sought advice and support to achieve positive outcomes for people.

Feedback from external professionals was generally positive about the quality and safety of care provided. Professional told us staff worked with them to support people and respond to their needs. However, some professionals expressed concerns about a recent lack of consistent leadership within the service and told us communication and information sharing had not always been timely. This had the potential to affect partnership working and the coordination of care.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

There were systems in place to monitor quality, review incidents and gather feedback from people, relatives and staff. Leaders used information from audits, review and quality assurance processes to identify areas for improvement. The newly appointed registered manager was continuing to embed these systems from within the service. This included strengthening processes to ensure learning from incidents was consistently identified, shared and used to reduce the risk of similar events occurring. Leaders also described how they had made improvements to the garden to ensure this was accessible to people living in the service.