Waterloo Manor Independent Hospital

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. The hospital now ensured that effective governance processes were implemented and followed to ensure safe care and treatment of patients.

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.

Staff understood the work that each of the wards was supposed to be carrying out such as what a forensic ward was and what they hoped to achieve. Staff did not mention corporate values when we spoke with them. However, they displayed a good understanding of the shared direction of the hospital, understood what they wanted to achieve. They understood the challenges that the people using the service faced.

During the assessment we saw processes that supported a culture which helped staff share knowledge and understanding, and a shared direction. There were opportunities for staff at different levels to come together and share good practice, learn from incidents and develop their skills and understanding. The organisational values were identified on the InMind website were. There was a company wide strategic plan shared with the assessment team.

Hospital senior managers we spoke with understood their roles clearly and how this fed into the running of the hospital. Managers had clearly defined roles, and these were explained throughout staff interviews. Staff that we spoke to said senior managers at the hospital were supportive and helpful despite some issues around staffing changes and recruitment. Some staff told us they saw senior managers on the wards supporting them in their roles.

Audits and governance processes demonstrated that leaders had the skills and knowledge to support patients effectively.

Staff generally told us they felt confident raising concerns to their immediate manager either through handover, team meetings or an individual basis. In some cases, staff said they could raise concerns to the clinical director and hospital director.

There were plenty of opportunities for staff to express their views about the way that the hospital was run, such as supervision, team meetings, and reflective practice. The hospital completed an annual survey whereby staff could provide feedback anonymously. The service produced a “You said, we did” for staff as well as patients. We were told the hospital had implemented a freedom to speak up process. This is not essential for independent hospitals. The deputy Chief Executive Officer acted as the freedom to speak up guardian. This meant that staff could raise concerns above the level of the registered manager.

A small number of staff told us they received late payment or had encountered issues related to their pay, although this appeared unrelated to any protected characteristic. Managers reported that action had been taken to address issues to ensure they were rectified quickly. Staff did not raise any concerns regarding the hospital not making reasonable adjustments or implementing flexible working arrangements. Managers explained there was a variety of support available to staff including occupational health and wellbeing being an agenda item for all supervisions.

The workforce was very diverse, with a large number of staff from overseas been employed in the 6 months before our assessment visit. As a result, the workforce did not reflect the local population. We did not find any human rights concerns during the assessment. We did not encounter any concerns related to the gender pay gap. At the time of assessment, training compliance for equality and diversity was 100% for the hospital.

Staff we spoke with understood their roles and responsibilities. We observed handovers on both wards and saw that managers clearly delegated individual roles and responsibilities to the team and that those staff appeared to understand their duties. Ward managers told us there were clear systems in place for reviewing incidents. This included a review of the number of incidents and incident type. Ward manager told us they were required to produce monthly clinical report which was presented within the monthly clinical governance meetings.

The service had made improvements and were no longer in breach of regulations. The hospital now ensured that effective governance processes were implemented and followed to ensure safe care and treatment of patients. The service also now ensured that effective audits were being carried out and that identified improvements are effectively actioned. There was an annual clinical audit program in place which the service used to identify areas of improvement. The organisation had recently undertaken a review of roles and responsibilities across the hospital. This included reviewing the staffing establishment, senior leadership and ward roles, and a review of staffing numbers. They had a followed a process in line with other In Mind services. There were systems in place to ensure incidents were reported. These were signed off by managers. The hospital kept data on incidents which was broken down into category, type and severity. Incidents were reviewed as an agenda item at monthly clinical governance meetings. Workforce planning was addressed at weekly resource meetings and daily staffing meetings. There were processes for staffing numbers, including criteria for when numbers needed to be increased. Ward managers provided a rationale to senior managers when they felt they needed additional staff. There were systems in place to ensure senior leaders were cited on information about risk, performance, and outcomes. We reviewed the minutes from 3 clinical governance meetings and saw that these were generally well attended and the minutes were comprehensive. The hospital director shared the clinical governance meeting minutes with staff via weekly bulletins. The hospital had implemented a new electronic care records system which went live on 15 April 2024. They did not raise any concerns regarding the reliability or security of the system.

Patients did not give any feedback about this area. However, other evidence showed that the hospital supported patients to work with their care coordinators and advocates where necessary.

Managers told us they met regularly with care coordinators and commissioners in professional meetings. There were fortnightly meetings with the IMHA in place and monthly meetings in place with the local authority safeguarding team. The service liaised with the NHS women’s pathway and a practice nurse also visited the ward to assess the physical health needs of patients and referred to external services where required.

Partners had no specific feedback on this area.

Care records identified that the service worked with a range of stakeholders throughout each patient’s journey on the ward. There were processes in place to ensure that the hospital worked in partnerships with people such as local authority safeguarding teams, advocates and other local service providers like GP's and physical health services. We did not identify any concerns with partnership working throughout the assessment.

Staff and managers told us about how work was monitored to enable them to learn and improve practice such as their involvement in reviews of serious incidents and discussions about lessons learnt. Ward manager told us about work that had taken place following a couple of incidents where patients went absent without leave. The service sought external support to develop better formulation of care pathways and strengthen their approach. Managers also told us about how staff made good use of reflective practice sessions following serious incidents. The hospital manager described a number of quality improvement initiatives including changes to the physical environment to ensure the kitchen could safely transfer food to the wards, changes to the ward representative meetings, a carers’ open day, regular recognition of staff via newsletters, the introduction of QR code for staff feedback, and the implementation of a hospital directors newsletters to improve communication.

There was an annual clinical audit program in place, which the hospital used to identify areas of improvement. When areas of non-compliance were identified, the hospital implemented action plans. The hospital conducted serious incident investigations which identified actions and learning. These were shared with staff.