Waterhouse Manor 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 dual registered service. This key question has been rated 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.

People who used the service, and their relatives, were invited to attend regular meetings where information about the service was shared. The manager encouraged feedback and suggestions to help drive improvement and ensure the service continued to meet people’s expectations.

There were regular handover meetings where up-to-date information about people’s wellbeing and any changes to their care was shared.

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 management team were motivated to make improvements and were working on an improvement plan, with processes and systems being implemented and embedded.

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

The providers had processes in place to support staff to speak up. This included supervision meetings, handover meetings, staff meetings and a whistleblowing policy. Staff had also received training in safeguarding to reinforce their understanding and their responsibility to speak up.

Staff said they knew about the provider’s whistleblowing policy and would not hesitate to use this to benefit staff and people living at the service. A staff member told us, “I would feel confident to whistle blow on poor practice. Residents’ safety and wellbeing is my priority. If needed I would contact head office or CQC.”

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 provider had policies to promote equality, diversity and inclusion and to protect staff from discrimination and harassment. No one raised concerns about unfair treatment.

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.

The providers had a large number of governance systems in place to monitor the quality and safety of the service. Regular walkarounds took place around the service to check the quality of care being provided and ensure the environment remained safe for people.

A programme of regular audits was carried out by the manager and regional manager. These covered key areas such as medicines management, health and safety, and care planning. Where improvements were identified, action plans were developed and progress monitored to ensure they were completed.

The manager monitored staff training needs. Staff told us they received the training they needed to carry out their roles and felt confident in their responsibilities. Training records confirmed staff received regular updates to maintain their knowledge and skills.

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 manager worked in partnership with the local authority, community teams and were keen to listen and learn to make improvements to ensure that they provided good care to all. Records evidenced appropriate healthcare referrals and appointments had taken place.

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 effective systems and processes in place to ensure lessons were learned when things went wrong. Accidents, incidents and safeguarding concerns were reviewed and analysed to identify any emerging themes or patterns. Where necessary, changes were made to practice reducing the risk of recurrence and improve outcomes for people using the service.

Information and learning from incidents were shared with staff in their daily meetings and staff meetings. This helped ensure staff remained informed and supported a consistent and proactive approach to safety and risk management.

The manager demonstrated a clear understanding of their responsibilities under the Duty of Candour. They were aware of the importance of being open and honest with people using the service, their families, and other relevant parties when incidents occurred that had caused, or had the potential to cause, harm. The manager confirmed they would provide timely apologies and share relevant information in a transparent manner.