Waterloo 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 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 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 registered manager was clear what the aims of the service were and the standards expected. This helped promote a positive work environment for staff and a home where people could receive safe care and treatment.Newly recruited staff completed an induction and probationary period at Waterloo House. Their work and progress were regularly reviewed and assessed during the probation period to ensure staff followed the provider’s policies and procedures. Probationary periods were extended if a need for further support was identified. Senior staff monitored staff practice so they could be sure staff demonstrated the provider’s values. On the providers, website, a value was, ‘We provide compassionate residential care in a warm, nurturing environment where dignity, respect and quality of life come first’. People’s feedback confirmed staff reflected this value and were respectful and kind.

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.

People and relatives were complimentary of the management team. One person told us, “[Registered manager name] is very nice, she’s a good manager. If you want anything done, she will do it. I would say it’s well run and I would definitely recommend it.”

Staff said the registered manager and deputy manager were supportive, approachable and when needed, supported them to help people. The registered manager said they spent time ‘on the floor’ helping staff and being seen so anyone who wanted to, could speak with them. The registered manager said they had a capable team who provided good care to people. The registered manager was clear about their role and was responsive when issues needed to be tackled.

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

Staff felt confident to raise any concerns or feedback to senior staff and management. The registered manager told us they had regular meetings with staff, heads of department meetings and they had an ‘open door’ so they were always available to hear any feedback.

People told us they felt able to raise any issues and relatives were confident to speak to the registered manager. One relative said they always saw the registered manager in the home and could speak to them, without prior arrangements. The provider had additional processes to support staff to speak up. This included supervision meetings and daily handover meetings.

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 registered manager told us they had a diverse staff group who worked well with each other and with the people they supported. The registered manager gave examples of how they valued their staff. For example, they had temporarily changed 1 staff member’s working pattern to support them to follow their cultural beliefs.

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

The provider had a system of quality assurance that included regular checks on the quality of service. This included checks of health and safety, the environment, care records, equipment, infection control and incidents and accidents. We also saw the registered manager monitored clinical outcomes for trends and patterns.

However, we found some audits and checks when delegated to others, had limited oversight. This meant when those checks failed to identify issues, some of which we found during our inspection, there was no evidence improvements were known and followed through. We checked examples of fire safety checks, care plan reviews and medicines management and found shortfalls and a lack of knowledge, of what was required. The registered manager assured us they would address this and before we left the service, they had begun to add further checks. People and relatives, we spoke with said they were not aware of or included in care reviews however the registered manager told us they had been asked. Despite this, relatives said their views and feedback was heard and acted upon which made them feel involved.

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.

People and relatives felt involved in how their care and support was shaped around them. People said and records confirmed, partnership working helped support positive outcomes. Some people saw external health professionals such as chiropodists, dietitians and district nurses. Frailty nurses supported people in the home when required. Senior staff engaged with commissioners to help families to understand everyone’s role in finding possible solutions to continued care. External relationships were supported and encouraged, especially within local communities. Waterloo House had partnered with a local dementia café so 1 person who lived locally, could continue to have important relationships with those they had known for a long time. A staff member took 1 person into Stratford upon Avon so they could buy the brand of coffee they preferred because it could not be bought online. Staff had set up a ‘wishing tree’ in the home which people could add notes to saying what they wanted to do. The registered manager said this was new and last month, 1 person went to a local butterfly farm because they loved nature. More was planned for this in future to get more people to do things they wanted to do.

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 registered manager said they continued to look at training to continue to educate and upskill staff. The registered manager said they were looking at de-escalation training to manage certain situations. The registered manager said rather than online training, “We do face to face, we used ourselves for staff to practice on around different behaviours, using equipment. We have done this since summer 2025.” Following training opportunities, managers completed staff spot checks of their practice. The registered manager said face to face training had been successful and added, “Staff are getting better with their strategies to keep people safe.” They planned further training in safeguarding and distraction techniques for to improve staff knowledge and keep people safe.

The registered manager told us following an infection outbreak in November 2025, they had sought additional training from local authority infection control teams to make sure they and staff continued to follow good practice.During our visit we identified some improvements were required around fire safety, medicines management and improvements to record keeping. The registered manager was receptive to this and assured us they would improve some practices. Systems were in place to gain feedback and to take learning from people, relatives and staff through meetings. Some suggestions had been adopted.