Waterloo 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 as requiring improvement. At this assessment, the rating has remained required improvement. This meant the management and leadership were inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was previously in breach of the legal regulation in relation to good governance. Improvements were not found at this assessment, and the provider remained in breach of this regulation. In addition, we found the provider was in breach of legal regulations in relation to the notification of other incidents.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Throughout the inspection, the registered manager was open, honest, and recognised improvements were needed. However, the registered manager and provider did not demonstrate sufficient oversight of the service to ensure people received care and support that promoted their wellbeing and protected them from harm. Poor judgements and decision-making potentially placed people at risk of harm and risked compromising people’s rights.This contributed to a breach of regulation in relation to good governance.

The registered manager had a clear vision for the service; the management team and staff were passionate about achieving the best outcomes for people.

Staff told us they felt the service was managed well, comments included, “[Registered managers name] comes from a completely different background and I think she has taken some time to readjust, but she is brilliant at what she does and she has the residents always in mind when she does anything and I think she is a good manager,” “It has been a stressful time with managers but now [Registered managers name] has took over it is more stable and things are getting done and now it is a really nice place to work,” and “I do feel that [Registered managers name] is an amazing manager and doesn't always get the credit she deserves, she has made a huge improvement to Waterloo House and this is appreciated by staff and residents.”

Relatives had confidence in the management of the service. Comments included, “Very well run, it wasn’t always like this,” “I have full confidence in the current manager,” “I would talk to [Registered managers name] or any member of staff. I have found them all to be very supportive. I feel the home is well managed,” and “I don’t know the name of the manager at the home, I do feel it is run efficiently.”

Leadership was sustained through safe and effective recruitment.

Policies and procedures supported an open and inclusive culture, where staff at all levels of the organisation were encouraged and supported to ‘speak up’.

The management team fostered a culture of openness and honesty when things went wrong. The provider had policies in place to support staff to speak up, raise concerns, and keep people safe. Staff told us the registered manager was available and approachable, and they could raise any issues or worries they may have with them. One member of staff said, “[Registered manager’s name] is very approachable, and it is easy to talk to her when I have any concerns.” Another said, “[Registered manager’s name] is totally approachable, she is a good manager and sets the tone. I would feel confident if I had any grievance or issue, or if I needed to whistle blow.”

The registered manager worked openly and transparently when incidents occurred at the service in line with their responsibilities under the duty of candour. Relatives told us that when they had raised concerns, the registered manager had acted promptly by investigating and resolving issues to their satisfaction.

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.

The providers’ oversight and governance of the service were ineffective in identifying failings in relation to the safety, quality and standard of the service as detailed in the safe, effective, and well-led sections of this report.

The registered manager and governance lead described the systems and processes in place to monitor the service and ensure compliance with the regulations. Each month, they undertook a range of spot checks and audits to monitor the quality and safety of the service and ensure compliance with the regulations, which were sent to the provider to review. However, we found the registered manager had not sent governance reports to the provider since November 2024.

We found governance processes were not effective in keeping people safe, protecting people's rights, and ensuring staff had the necessary skills to meet people’s needs. This meant they did not drive improvement, did not identify the issues we found at this assessment, and could not be relied upon to measure the quality or safety within the service. Issues included concerns with the management of people’s medicines, management of risk, person-centred care, staffing, and training.

The provider had not ensured staff understood the principles of the MCA. This lack of knowledge and understanding risked compromising people's rights.

Systems were not fully embedded into practice or robust enough to demonstrate accidents or incidents were effectively monitored, reviewed, or used as a learning opportunity.

The provider’s oversight and governance of the service had been ineffective in identifying failings in relation to the safety, quality and standard of the service as detailed in the safe, effective, and well-led sections of this report. This contributed to a breach of regulation in relation to good governance.

The registered manager understood their responsibilities in relation to the duty of candour. Duty of candour requires that providers be open and transparent with people who use services and other people acting lawfully on their behalf in relation to care and treatment. However, we found systems had not been effectively operated to identify and report significant events. This had led to the provider not notifying the Care Quality Commission of 6 significant events in line with their legal responsibilities.

This was a breach of regulation in relation to notifying CQC of significant events in line with their legal responsibilities.

In addition to the auditing process, the registered manager told us they held regular virtual meetings with the provider to discuss the service, staff, and people. This enabled them to identify any concerns, agree on actions, and monitor progress on existing action plans.

Throughout the assessment, the registered manager and governance lead acknowledged the service was not where it needed to be and were keen to address any areas of concern. Following the assessment, the registered manager sent the Commission a copy of their updated service improvement plan.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The registered manager and staff told us they recognised the importance of joint working and in partnership with people, their families and other healthcare professionals to improve people’s outcomes. For example, the local hospital, GPs, and district nurses. However, we found this information did not always form part of people’s planned care arrangements, and staff had been slow to raise/escalate concerns or seek advice in a timely manner. This impacted the quality of care people received and placed them at an increased risk of avoidable harm.

Prior to the assessment, we received feedback from the local authority, which raised concerns about the provider’s ability to follow advice provided by external agencies following a recent safeguarding concern.

There was limited information to show how the provider was empowering people in the development of their care and support or engaging with them in understanding their rights.

This contributed to a breach of regulation in relation to good governance.

People spoke positively about the service, the staff, and the management team and felt able to raise concerns. Relatives had confidence in the care provided and felt the staff communicated well. However, relatives told us they had not been formally asked for their views or to provide feedback.

Systems and processes were in place to show how the provider worked in partnership with key stakeholders. Some care plans demonstrated the service actively engaged with people and their families and sought support from a range of healthcare professionals. Regular meetings and handovers helped to ensure information was shared with staff at the right levels.

The governance lead told us systems were in place to gather people's, relatives’, and staff feedback on the quality of the service. However, these were not available at the time of the assessment.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. At the time of the assessment, there was limited information to demonstrate how quality assurance and compliance systems were being used to identify areas of concern and drive improvements.

Learning did not take place from accidents and incidents. For example, accident and incident analysis did not reflect the levels of incidents taking place or identify if appropriate action had been taken. This meant this information could not be relied upon as a source to measure quality.

Feedback was not sought from people, relatives, staff and other health and social care professionals or seen as an opportunity to support learning and development.

This contributed to a breach of regulation in relation to good governance.

Throughout the assessment, the management team were open, acknowledged any areas for improvement and were keen to put processes in place to address any areas of concern or improve practice. They talked about how they would use our feedback to develop the service improvement plan, improve the culture within the service, and measure progression.

The registered manager described how they promoted continuous learning through meetings with staff to discuss work practices, training, and development needs. They told us recent appointments of a new deputy manager and governance lead would positively impact service delivery and governance.

Concerns and complaints were listened to and acted upon to help improve the quality of the care and support provided by the service.