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 are 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, and defibrillators were regularly serviced and safe to use.

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.

Although most patients told us they felt safe to raise concerns, they did not feel anything would be done about them. Several patients told us they were not debriefed following incidents. However, the hospital complied “You said we did” updates using information gathered feedback from both staff and patients. Leaders sought feedback within community meetings.

Managers we spoke with could provide examples of continuous improvement. Ward level team meetings also gave managers the opportunity to share learning. Staff that we spoke to said they had regular team meetings. The service employed patient safety officers who supported ward staff to manage incidents, conduct debriefs and supported the safeguarding of patients. However, whilst process 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 understood. The incident reporting process prompted staff to consider duty of candour.

Patients had clearly defined pathways. For those who needed alternative placements we saw work was ongoing to facilitate this. One of the wards was in the process of being repurposed and all patients were being transferred elsewhere. Staff were working hard to make sure this happened safely. However, one patient told us they had moved wards suddenly due to a paperwork error, which they were unhappy about.

Staff and leaders told us there were systems in place to monitor safety and to support people to recover. We observed 2 evening handovers. These were well attended and the nurse in charge gave a comprehensive handover.

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. The specialist advisor did not identify any concerns with the admission/ discharge process during a review of care records.

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. Care records showed that patients and staff worked together to identify objectives and goals to prepare them for discharge.

Some patients told us they felt safe and said that staff were supportive. However, other patients disagreed with clinical decisions around their care, for example whether they should be on 1-to-1 observations to keep them safe.

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.

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.

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. 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%. 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 and in multidisciplinary meetings. Although there may have been disagreements between patients and clinicians, patients still told us about the different ways in which they were involved.

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 the reintroduction of items that were removed from patients to help keep them safe. Risk management and mitigation was reviewed daily during 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.

The service had made improvements and now ensured that risk information in patient records was clearly identified and up to date. We reviewed 4 risk assessments and found these were detailed, updated regularly following incidents and MDT meetings, reflected patient’s current risks, and restrictions were identified and implemented on an individual basis. 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 Cedar and Maple ward and saw that in nearly all cases these were fully completed with the observations being carried out within the prescribed timescale. The service now ensured that staff were following the seclusion policy and the Mental Health Act Code of Practice when secluding patients. The assessment team reviewed recent seclusion records and found these had been completed accurately within the forensic service. However, the service conducted an audit of seclusion records in March 2024 on Cedar ward. None of the records achieved the required benchmark compliance. Five out of 6 records did not have a seclusion plan in place. The subsequent audit in May 2024 identified all records to be fully compliant.

Patients we spoke to told us that the environment and décor were improving. 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 substantial 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 much better state of repair. The seclusion room was now well maintained, clean and fit for purpose. Defibrillators were now regularly serviced and safe to use. 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 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.

Some patients said that staff did not understand them and what they needed, with 1 commenting that “some staff don’t always understand English.” We spoke with 3 out of 7 patients who felt the wards were understaffed. At times this was because the patient felt they should be on 1-to-1 observations. However, patients generally said they could get support when needed.

Some staff and leaders shared concerns that some staff recruited as part of the overseas programme had limited use of English and described communication problems. 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. However, the majority of staff felt that there were enough staff and 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. 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.

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 both 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.

Patients on both wards said that communal areas, bathrooms and bedrooms were cleaned on a regular basis.

The hospital employed a team of housekeeping staff and there were cleaning rotas in place. 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. Furniture had all been replaced since we last visited and it now met infection prevention and control requirements with no rips.

The service had made improvements and were no longer in breach of regulations. The hospital 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. 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. There was a catering, hydration and nutrition policy in place.

Patients told us their medicines were reviewed regularly and they could access their medicines when needed. However, some patients said they were not given information about the medicine they were prescribed.

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

The assessment team reviewed prescription and medicines administration records on both wards. No concerns were identified. The clinic room on Cedar ward was orderly. On Maple ward the clinic was cluttered. However, it was functional and did not cause any identified risks.

The service now ensured that all patients checks are 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.