Waterloo Court

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• 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

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 was the first assessment of this 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.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

We scored the service as 3. The evidence showed a good standard. The service had a vision, strategy and culture based on transparency, inclusion, and equality. This was based on the needs of people and their communities.

The sole registered person had established the vision and values for both of their businesses as they were aligned. However, the other service was not required to be registered with us. These focused on improving the health outcomes of people and promoting collaborative working with other professionals where appropriate.

We scored the service as 3. The evidence showed a good standard. The service was managed by the registered person who understood the context in which they delivered care, treatment and support and embodied the culture and values of their service. They had the skills, knowledge, experience, and credibility to lead the service. They did so with integrity, openness, and honesty.

The registered person demonstrated they had the skills, knowledge and experience to carry out their role effectively. They showed a clear understanding of the service, including its operations, challenges and the needs of people using the service.

The registered person was approachable and maintained a presence that enabled people using the service and providers who referred people to them to raise concerns, seek guidance and engage in open communication. This contributed to a positive and supportive culture within the service.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture, however Freedom to speak up was not required as the registered person was the only member of staff.

The service was provided by the registered person and therefore did not require Freedom to speak up arrangements.

We scored the service as 3. The evidence showed a good standard. The registered person valued diversity in their workforce. They work towards an inclusive and fair culture.

The service was operated by a sole registered person, who was responsible for all aspects of service delivery. This provided consistency in care and oversight, with clear accountability for the management and operation of the service. The registered person had an equality and diversity policy.

We scored the service as 3. The evidence showed a good standard. The service had clear responsibilities, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment, and support. They act on the best information about risk, performance, and outcomes, and share this securely with others when required.

There was an established framework of audits to monitor the quality and safety of service provision. Following the registration assessment in February 2026, the registered person had taken action to strengthen oversight and governance arrangements within the service. During the site visit, we identified some areas for improvement in relation to policies and procedures. The registered person demonstrated insight into these findings and told us they would take prompt action to address them.

We reviewed a range of weekly audits undertaken by the registered person. These included monitoring of incidents, complaints, feedback from people using the service, equipment checks, and the number of blood collection sessions undertaken. Although these were recorded in a checklist format at the time of inspection, the registered person was in the process of developing a more detailed log to further enhance record-keeping and oversight.

A monthly governance meeting had been established with the associated private GP practice. We reviewed records of 2 of these meetings, which demonstrated relevant issues were regularly discussed, including environmental concerns and any complaints received. Actions were clearly documented and reviewed at subsequent meetings to ensure progress and resolution. For example, changes had been made to improve access to the treatment room, including the introduction of a separate entrance to prevent people from having to pass through another room.

The registered person had devised a risk register. Risks were all assessed, given a score rating and any action detailed. These were reviewed every 6 months or sooner if the need arose.

Information governance systems were in place to protect the confidentiality of people’s records. Information we reviewed was maintained, accessible, timely and accurate, and was used effectively to identify areas for improvement and drive service development.

The registered person was registered with Information Commissioner’s Office (ICO). The ICO is the independent regulatory body responsible for upholding information rights, data privacy for individuals, and access to public information.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The registered person demonstrated effective engagement with external stakeholders, including healthcare services who referred people for blood collection. They also maintained regular communication with the private GP practice where the service was based, supporting collaborative working and continuity of care.

As the service was delivered by a sole provider, the registered person had direct contact with people using the service. This enabled them to gather feedback in a timely and informal manner as part of day-to-day interactions. Such engagement supported a person-centred approach and allowed the registered person to respond promptly to any concerns or emerging needs.

Feedback from providers who referred people to this service was all very positive. They felt the communication was good, responded to feedback professionally and had adjusted the service as necessary.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation, and improvement across the organization. They encouraged creative ways of delivering equality of experience, outcome, and quality of life for people.

The registered person demonstrated a commitment to continuous improvement and innovation within the service. As the sole provider, they had the capacity to allocate time to review practice and identify opportunities to enhance the quality of care delivered.

This proactive approach enabled the implementation of changes to care delivery, supporting a responsive service that adapted to the needs of people using it and reflected ongoing service development.