Waterfield 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 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.

The provider’s values were shared with staff and were consistently measured by the systems and processes in place to assess, monitor and review quality and safety. The provider’s shared vison and culture was based on individuality, choice and dignity.

New staff received an induction and training which helped them to understand and demonstrate the provider’s values in their daily work with people.

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 leadership and management team were experienced, skilled and competent. The registered manager had been in place for 4 months on the date of our inspection. They had previously worked in other roles within the organisation. Relatives expressed confidence in their leadership. A relative said, “[Registered manager], I have always found very approachable. Easy to discuss things with, as has my relative. I feel very confident about Waterfield with her in charge.”

Staff also expressed confidence in the leadership team. A member of staff told us, “All in all I find Waterfield a good place to work, under good leadership.” Care staff were involved in developing and sharing ideas for improving people’s quality of life.

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

Information about speaking up was available to staff. Staff told us they felt able to raise concerns or make suggestions and these were listened to and acted on. A staff member told us, “If needed to raise any concerns, I do feel I would be able to approach the management team. I have full confidence in them and I know I would be listened to and things would be acted upon if needed.”

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 valued diversity within the staff team and demonstrated a commitment in supporting and valuing the staff.The registered manager gave us an example of pro-actively dealing with an incident regarding diversity.

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

Investigations into complaints and safeguarding incidents were not always recorded in a way which demonstrated a thorough investigation had been undertaken. Some recording was incomplete and other records contained generic information and did not contain details of actions taken to mitigate the risk. This had not been identified by the provider audits. Poor recording may mean that effective learning from concerns could not take place.

Audits had not identified that some care plan documents were generic or did not contain sufficient detail. For example, a person’s behaviour was being recorded on an ABC chart which is used to understand the causes of challenging behaviour. The recording stated, ‘was distressed’ and ‘was confused’ with no other information. Further detail is required to effectively identify causes of distressed behaviour.

Staff communication systems were effective in sharing important information about people’s care and treatment needs, and areas for development. Staff were clear about their roles, responsibilities and accountability.
There was a clear staffing structure which ensured there was always a senior member of staff available. This meant senior leaders were available for any support or guidance to both staff, people who used the service, relatives and visiting professionals. This supported the service to run smoothly.

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 provider worked in partnership with external organisations to provide meaningful engagement. Such as, a local coffee shop visiting the service to provide samples to staff and people, and yoga sessions to people from a local teacher. A person said, “I went to church here, vicar brought his keyboard, and we sang hymns that was lovely.”

There was a multi-disciplinary teamwork approach in supporting people with their care and support needs.

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 provider’s chief operating officer told us the organisation prioritised a culture of continuous learning by actively encouraging staff to engage in professional development and training. They told us the organisation participated in research projects and partnerships with the aim of improving care standards across the sector. This included a falls project which had reduced the number of falls for people.