Waterloo Manor Independent Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm. The hospital now ensured that the premises were clean, effective infection control measures were in place and the environment and furnishings were well maintained. The seclusion rooms were well maintained, clean and fit for purpose.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Each ward had a monthly ward rep representatives meeting where concerns could be shared. However patient feedback was mixed. Some patients told us that staff were open and transparent when things went wrong. Others told us they were not.

Managers used team meetings to share learning and gave examples of continuous improvement. Staff could provide examples of when they had apologised when things went wrong. For example, after a staff member had administered an extra dose of medication to a patient, staff made the patient aware and apologised to them. No harm was caused. They shared information with family and completed an incident report. The service employed patient safety officers who supported ward staff to manage incidents, conduct debriefs and supported the safeguarding of patients. However, whilst processes for learning were comprehensive, covered important areas, and were well embedded, staff and patient feedback suggested that some issues and challenges appeared to remain; this included staff concerns around incidents, safety, staffing, and wellbeing of staff.

Processes were embedded to identify concerns across the service and enable learning. Monthly clinical governance meetings covered a range of standing agenda items which senior leaders used to identify concerns/ themes relating to issues including staffing, incidents safeguarding, infection prevention and control, and medicines management. There was a duty of candour policy in place which staff followed. The incident reporting process prompted staff to consider duty of candour. The hospital complied “You said we did” updates using information gathered and feedback from both staff and patients. They also sought feedback via morning meetings and community meetings and through a staff survey.

Patients had clearly defined rehabilitation pathways. Some patients were part way through their pathways whereas others were close to discharge. Patients and carers told us they were involved in discussions about their pathways where patients had given consent.

Staff told us they arranged for patients to visit/ stay at prospective placements prior to finalising discharge. They described clear pathways for ensuring the safe transition of patients.

Partners did not give us feedback about this quality statement. However, the service worked with external teams to plan and facilitate transfer or discharge. They invited external teams to multidisciplinary team (MDT) meetings and Section 117 discharge planning meetings. The specialist advisor did not identify any concerns with the admission and discharge processes during a review of care records across the rehabilitation wards.

There were no concerns identified throughout the assessment regarding transitions. For example, we did not encounter any delayed discharges and were not alerted to any issues with joint working that impacted pathways or transitions. Staff followed a standardised process for transfer and discharge. They shared treatment plans, risk assessments and other relevant documents with partners as part of the transition. Staff told us they arranged for patients to visit/ stay at prospective placements prior to finalising discharge. Care records showed that patients and staff worked together to identify objectives and goals to prepare them for discharge. There was a focus on developing activities of daily living. However, some patients however, told us they didn’t understand their goals.

Patients told us they felt safe, that staff were supportive, and they felt confident to raise concerns.

Staff we spoke with knew the patients, their individual risks and any potential safeguarding concerns. Staff generally understood the processes for making safeguarding referrals, they knew what to report and who to report it to. There were good relationships with the local authority. Work that staff and leaders carried out demonstrated a commitment to keeping people safe from abuse and neglect. However, not all staff had a good understanding of the Mental Capacity Act 2005 (MCA 2005). Some staff could not explain how the Act applied to their role or describe the 5 key principles.

We observed two evening handovers which also demonstrated that staff were briefed on current risks, and individual need to try safeguard patients. Our observations raised no concerns regarding safeguarding at the service. The assessment team did not identify any human rights infringements, sexual safety concerns, or evidence of closed cultures during the assessment. There were no patients who were under Deprivation of Liberty Safeguards (DoLS) at the time of assessment. However, we did note restrictions regarding visits not taking place on the wards.

There was a safeguarding policy in place which was subject to regular review. At the time of assessment, safeguarding adults training compliance across the hospital was 99% and safeguarding children was 97%. There were clear processes in place for submitting safeguarding alerts. These were reviewed by ward managers and discussed as an agenda item at monthly clinical governance meeting. Managers made sure that records adhered to safeguarding requirements through a safeguarding audit. In the most recent audit, all 22 records audited were fully complaint. Lessons learnt were identified through the analysis of cases.

Patients told us they were involved in developing their care plans, including care plans for restraint if these were appropriate. Patients confirmed they had access to fresh air and an outdoor space. Most patients said staff used de-escalation techniques prior to physical restraint. However, two patients told us that night staff fell asleep on shift. When we raised this with managers, they gave an example of the action taken when they had been made aware of this.

Staff told us a range of ways in which risk was understood and managed. Staff worked with patients to develop formulations to understand risks and produced positive support behaviour plans to try and reduce risks and distress and enhance patient’s wellbeing. Staff described positive risk taking. This included implementing unescorted leave plans for patients who were at risk of accessing alcohol or drugs. They devised individualised plans to try and reduce risks. Risk management and ways to reduce risk were reviewed during daily handovers. Staff identified some blanket restrictions that were recorded on the blanket restrictions log. Most restrictions were individually care-planned. Managers reviewed staff’s observations competency during supervision.

We reviewed 6 risk assessments and found these were detailed, updated regularly, and reflected patient’s current risks. Care records demonstrated that risks were assessed on an individual basis, with any restrictions put in place based on the need of the individual. The nurse in charge conducted daily checks of observation records to check that staff were completing and recording observations appropriately. We reviewed a sample of observations records for all patients on Lilac and Hazel ward and saw that in nearly all cases these were fully completed with the observations being carried out within the prescribed timescale. However, on 6 May 2024 two hourly-observation entries had been left blank in one patient’s record. In addition, staff did not always sign the designated space on the form to indicate which staff member they had handed the observation record over to. Training compliance for physical intervention training (breakaway) was 90% across the hospital and for physical intervention (holds) was 95%.

Some patients fed back that décor and furnishings were tired, and in need or renovation. However, they did not raise any specific issues that raised questions about the safety of the environment.

Managers completed regular walk rounds of the wards to review ward environments.

The hospital had carried out improvements to the environment and were no longer in breach of regulations. Furniture had been replaced, decorating had been carried out and generally the wards were in a better state of repair. The seclusion room was now well maintained, clean and fit for purpose. However, the sensory room was cluttered and with limited sensory equipment. We observed staff carrying out checks of the environment. There were some blind spots, but these usually were mitigated by mirrors or by increased observations where necessary when patients were a higher risk of harm. There were some areas which patients could not access without staff assistance if this was appropriate. This included the patient kitchen due to the risk of patient’s self-harming. The wards were accessible for patients with physical health needs to ensure their safety.

There were systems and processes in place to ensure work was carried out to keep the environment safe. These were audited on a regular basis and action was taken where needed. There was a service improvement plan in place which set out action date for maintenance and environmental works. This included a decorating schedule which was reviewed by senior managers. The assessment team reviewed a sample of the security check records and saw these were up fully completed with no gaps or omissions. We looked at defibrillators on two of the wards and saw that these were in working order and subject to the appropriate checks. There was a business continuity plan in place.

Nine of the 11 patients we spoke to said that language barriers made it difficult to communicate with staff recruited as part of the overseas programme. Three patients felt there were not enough staff. However, other patients told us they did not need many staff because they were more independent. Patients generally said they could get support when needed. All the carers we spoke to told us there was a high turnover of staff and two felt this impacted on communication. One carer also commented that their family member “needed staff she can understand”.

Staff and leaders shared concerns that some staff recruited as part of the overseas programme had limited use of English and described communication problems. Some staff gave examples of when this had impacted on therapeutic engagement or patient safety. The clinical director and the ward managers we spoke with were aware of these concerns and said patients and staff had raised this with them on multiple occasions. The hospital’s site improvement plan identified the following actions to address this: “Staff meetings and community meetings continue to be held and viewpoints of both staff and patients noted. Ward managers have identified the international staff who appear to have difficulty in their communication. This has been discussed through supervisions and within the probation period an action plan has been formulated.” Managers also supported staff with English courses and if necessary extended probationary periods to ensure staff were sufficiently skilled and experienced. Staff on Hazel and Larch wards told us they did not always feel there were enough staff which can result in leave being postponed. Some staff told us they did not feel safe on the wards, due to both staffing and the levels of acuity. We reviewed the incident data for the previous 6 months and found the rehabilitation services had seen an increase of incidents in January 2024 on Larch ward. However, this had decreased in the following months. Managers described working “smartly” and effectively to make best use of staff and try to ensure safe care. Patient safety officer roles had been created who supported with debriefs, and incident management. Staff felt that they received sufficient training and support to carry out their roles. Staff attended regular supervision which was monitored hospital-wide through the clinical governance meeting.

We spent time observing care on the wards during the day and during an out of hours visit. The care we saw being delivered looked safe and effective. Staff appeared to have good rapport and an understanding of the patients they were caring for. We observed handovers on the wards. Staff we spoke to, gave us a good understanding of the patients they were caring for. However, a couple of international staff members did not understand a some of the questions asked.

The parent company had undertaken a review of staffing which resulted in a reduction of staffing numbers across the hospital. Managers were able to request more staff when they needed for example if there was a patient on enhanced observations. There were systems in place to ensure that staff had the appropriate skills, qualifications and training to undertake their roles. This included regular supervision, high completion of mandatory training, and a comprehensive competency framework. All training courses were above the company’s required training compliance of 85%. The service now ensured that all staff were offered regular supervision and the opportunity to attend regular team meetings. There was a performance management policy in place. The registered manager described how they worked closely with human resources to ensure the correct process was followed. They described how performance management focussed on developing the staff member to help them better understand the nature of the role. However, at the time of assessment there were some vacant posts including a forensic psychologist, a responsible clinician, a physical health nurse, a social worker, and 2 patient safety officers.

On some of the rehabilitation wards, patients undertook cleaning duties as part of their recovery. This included cleaning of their bedrooms and communal lounges, dining rooms and kitchens. Patients told us the wards were clean and staff helped them if needed. However, one patient told us they felt the wards could be cleaned more regularly.

The hospital employed a team of housekeeping staff and there were cleaning rotas in place. Staff implemented personal hygiene plans for patients who struggled with personal care. These were done in line with best interests’ decisions. Staff did not raise any concerns about infection prevention and control.

There were adequate supplies of cleaning products, handwash and personal protective equipment on the wards. The hospital now ensured that the premises are clean, that effective infection control measures are in place and that the environment and equipment are well maintained and safe to use.

The service had made improvements and now ensured that the premises were clean and that effective infection control measures were in place and being observed. There was an Infection prevention and control policy in place which was up to date and subject to regular review management. There was a catering, hydration and nutrition policy in place. We did not identify any concerns with food hygiene. The hospital used trolleys to transport food from the kitchen to wards. The food safety inspection of the catering team in 2023 resulted in a 5 stars rating. However, we found gaps in the daily fridge checks for the communal fridge on Lilac ward.

Patients told us they understood what medication they were taking and that their medicines were reviewed regularly. They could access their medicines when needed and some patients were self-medicating.

Staff that were involved in medicines management understood it well and did not raise concerns.

The assessment team reviewed a selection of prescription and medicines administration records. No concerns were identified. The clinic rooms were clean. Equipment was available to monitor physical health and emergency equipment was in place.

On Lilac ward, there was no evidence the emergency bag had been checked during the two weeks prior to our visit. The blood glucose machine was available but there was no evidence of calibration and although the clinic room appeared to be clean, we could not find cleaning records to evidence regular cleaning. However, we had no concerns about the clinic room, emergency equipment or record keeping on Larch ward. On both wards clinic temperatures were monitored, medicines were stored safely and were in date and emergency medicines were available. The service ensured that all patients checks were carried out and recorded accurately and in line with national guidance following the use of rapid tranquilisation. Where patients refused the checks, breathing rate was recorded. Monitoring was completed for patients on high dose antipsychotic medicines. Capacity assessments were completed when necessary and appropriate legal documentation was in place.