Watermoor 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

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 Requires Improvement. At this assessment the rating has changed to 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 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

Leadership at the service was good. The registered manager was described positively by staff. Staff told us they felt valued, supported and listened to. They spoke of leaders who were approachable, compassionate and actively present in day‑to‑day care.

They had made improvements since the previous inspection. For example, the provider had ensured all policies were available for staff and evidence staff have read and signed. The registered manager now had oversight of review of policies, and these were now included in induction packs. The staff handbook had been updated and cross-checked against existing policies. Signature sheets from the staff handbook and induction pack were collected and stored on personnel files.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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 registered manager had begun to strengthen governance arrangements with the board of trustees, and there was evidence of improving oversight across key aspects of the service. Systems for reviewing incidents, audits and care documentation had been introduced or revised since the last inspection, with the registered manager working together with other leaders to support improvements in quality, safety and record‑keeping. However, these systems were not yet fully embedded, and further work was needed to ensure they were applied consistently.

For example, audits varied in quality and consistency. Wider governance tools, such as risk‑management processes, escalation pathways, and oversight of clinical assessments, were still developing and had not yet achieved sustained, reliable practice in areas such as fluid monitoring, escalation of concerns, and care‑plan accuracy.

Governance systems were improving but needed further time to embed.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

While the provider did focus on continuous learning, innovation and improvement across the organisation and local system, they were inconsistent with delivering equality of experience, outcomes and quality of life for people. They did not always actively contribute to safe, effective practice.

The provider had made some improvements since the previous inspection and had now created a service improvement plan to monitor and drive improvements. There were now consistent systems and processes to record lessons learnt. However, this still needed further improvement and time to embed these new processes.

The provider had introduced a complaints log which showed a clear record of how they were managing and responding to complaints. We saw evidence of resident meetings, however; this did not always reflect the feedback we heard from people. For example, people told us when they made suggestions to staff around medicines management and mobility equipment, they were not supported and staff were dismissive. One person told us, “'I’m not allowed to have vitamins or take my tablets myself; they make such a fuss about it, they say it’s the law. If I went to the shop, I could just buy vitamins, it's ridiculous really. Staff here would just take them off me and say I'm not allowed them so now I don’t bother but I would like them if I had the choice." Other people told us they would like the staff to listen to them about getting different walking aids, however we did not see evidence the manager was aware of these conversations. The absence of these concerns being recorded by the staff and handed over to the manager meant there were still some shortfalls in how information was cascaded. The absence of a clear record meant managers could not assure themselves they were consistently hearing people’s voice.