Waters Park House

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 75 (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.

The registered manager and her management team had a vision and desired culture which they actively shared with the staff team. The staff team demonstrated a positive culture and worked well together to deliver the best outcomes possible for people using the service. For example, the MDT therapists took part in the delivery of personal care and activities, as well as delivering their therapies. They also delivered most of their therapeutic work with people in their own rooms rather than using the separate gym area. This approach delivered a close team-based approach to peoples care and rehabilitation.

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.

The service’s registered manager and the provider had been with the service for many years, so there had been consistent leadership. They understood the context in which the service delivered care, treatment and support. The service leaders were visible within the service and led by example to their staff team, demonstrating inclusive behaviours.

Staff we spoke with were positive about the support given by the registered manager and management team. The impact of the management approach was demonstrated by the low staff turnover, with many staff remaining with the service for some years.

The service fostered a positive culture where people, their relatives and staff could speak up and their voice would be heard. People, and relatives, were confident if they raised concerns to the service these would be effectively addressed by the leaders of the service.

The service managers described a highly ‘open door’ culture where they did not leave issues to be dealt with at booked appointments but rather encouraged anyone who might have any concerns to immediately “come and grab us” (senior staff). This meant any issues were addressed without delay. This approach appeared to reduce the formal complaints procedure being necessary, as the service had not received a formal complaint for some time.

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.

Staff told us they worked well as a team and did what they could to help each other. Staff members told us how service leaders knew them personally and were committed to be being flexible. This meant the staff member could work effectively around their other commitments outside of work.

Staff were of different ages, national backgrounds, ethnicity, gender, sexual orientation and experience. Such a diverse workforce was a positive benefit to the culture of the home, promoting innovation in practice. For example, staff brought their backgrounds and traditions to the activity in the home, including theme days based around festivals, with food and drink from other countries. The service demonstrated equality, diversity and inclusion in practice.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Oversight and governance of the service was taking place. The registered manager and the management team had awareness of the quality of the service and were accountable for ensuring the present quality was maintained and continued to improve. Staff and relatives were positive about the quality of the service.

The audit system was paper based but a new IT system covering all aspects of the functioning of the service was to be implemented soon. Paper based audit processes were in place. There were some issues that had not been identified by the governance systems including the lack of some recording. For example, related to supervision sessions taking place. However, the governance arrangements had identified other issues we found at this assessment, including, issues in the environment at the service and the completion of required training.

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.

The service worked well with other stakeholders and services to support people. This included commissioning local authorities and health services, who had full confidence in the management of the service.

The service worked effectively with health and social care professionals involved in each person’s care. There was a relationship of trust and confidence between the service and their GP surgeries.

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.

The service was well led and demonstrated a commitment to further improvement. The registered manager and MDT was delivering a learning culture in the service, so the service met the needs of the people and continued to innovate and develop. The formal feedback system to gather the views of people, relatives, staff and professionals was not supplying useful information. As a result, the service relied on the informal feedback from all these stakeholders through their open communication culture. The registered manager said they would review and make changes to their formal feedback survey system to develop a more effective method of collecting formal feedback, from which they could then identify further possible improvements and develop action plans.