Lakeside Watermead Care Home

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.

This is the first assessment for this newly registered service, following a change in provider. This key question has been rated requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulations in relation to governance at the service which included record management.

This service scored 61 (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 clear shared vision, strategy and was working to develop a culture based on transparency equity, equality and human rights, diversity and inclusion and engagement.

The service had a vision and values poster on display which indicated they provide care and support with respect, dignity and participation to promote choices and positive outcomes for people. They seek feedback and review care to provide good quality care and meet regulations with an investment in their staff team.

We received mixed feedback from staff on the culture of the service. Some staff felt able to raise issues and these were addressed. Whilst other staff felt their concerns were ignored, not acted on. This was fed back to the provider to act on and address to promote an open culture within the service.

Whilst leaders understood the context in which the provider delivered care, treatment and support, they were working on developing the culture and values of their workforce and organisation to lead effectively to develop their team

We received mixed feedback from people and their relatives about the provider and management of the service. Some people and relatives could see improvements within the service, such as in the providers engagement with them. Other people and their relatives were still uncertain whether the change in provider was positive for them. A relative commented, “It is hoped the new manager will be a morale boost for the service.”

Some staff felt the new manager was experienced, knowledgeable and approachable. Staff commented, “Management is approachable and always ready to help or offer guidance when needed, which creates a positive and team-focused working environment”, and “The new manager is fair, approachable and I feel happy to raise issues with them.” Other staff told us that their concerns about staffing levels were not listened too. A staff member commented, “Staff has repeatedly tried to contact the new management regarding multiple issues. However, they do not respond to calls, messages or emails and fail to let the team know of staff absences.’” This feedback was shared with the provider for them to investigate, respond too and act on to promote an inclusive approach to the management of the service.

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 promote speaking up. These included a whistle blowing policy, team meetings and supervisions.

People, relatives, staff and professionals were surveyed. The results of the surveys completed in 2025 were mixed with issues raised around staffing levels, training, aspects of care and activities. An action plan was in place to address the findings and make improvements.

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.

The service had a diverse group of staff employed, with systems in place to support them with their religious and cultural needs. The provider accommodated flexible working for staff to enable them to meet their family commitments which enabled the provider to retain key staff members.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Whilst auditing had commenced and issues were being identified, auditing processes were not fully embedded in practice to promote effective monitoring to enable the provider to identify the shortfalls we found in the service. The provider was committed to addressing this to promote good governance.

People’s records were not always suitably maintained and accurate. Some people’s records were contradictory. For example, if there were support needs around emotional health or when a person’s weight became a concern. Other records were not completed to indicate people were repositioned, checked, weighed or showered at the frequency required. The provider had introduced an electronic care planning system. They were supporting and training staff to use the system effectively to improve the recording on people’s records.

Some terminology used in records was not in line with best practice. For example, a person was described as ‘lazy and messy’ in relation to their continence care. Other people were described as ‘challenging and aggressive’. The provider had commenced a review of people’s records to identify language recorded that was not in line with best practice to ensure records were respectful and person-centred.

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 and leaders were open and transparent, and they collaborated with all relevant external stakeholders and agencies. As a new provider they were building on relationships with health professionals to promote partnership working and develop community links.

The provider was committed on continuous learning, innovation and improvement across the organisation and local system to enable them to actively contribute to safe, effective practice and research.

Whilst systems were in place and being developed to promote continuous learning, these were not yet fully embedded in practice. However, the provider was committed to improving the service. They were proactive in acting on our feedback and were working with the Local Authority to improve the service. A service improvement action plan was in place to monitor the progress.