Waters Edge Care Home

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

People, staff and relatives found the management team to be approachable and responsive. The registered manager was aware of their roles and responsibilities. Safeguarding referrals were made when needed and statutory notifications were submitted to the CQC. Audit systems were in place to check the quality of the service. The registered manager had clear oversight of any accidents, incidents and safeguarding's and escalated any concerns when necessary. Additional audits were undertaken by the provider to add a higher level of oversight at the home. Where concerns were identified, action was taken to address these and reduce the risk of reoccurrence.

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.

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.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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 provider had daily checks in place that enabled them to check the quality of the service. Accidents and incidents records were checked by the registered manager daily and action taken. We saw 'service user of the day' documentation which ensured that each person living at the home had all of their care records, documentation and equipment checked once a month. Systems were in place to oversee and manage risk. Risks were identified and risk assessments were reviewed on a monthly basis to ensure they were up to date. Where there were changes in people's risks, these were updated immediately. We saw risk assessments in place for risks such as falls risk, skin integrity, PPE, nutrition. Risks were also clearly identified in people’s care plans and clear guidance was in place for staff to meet peoples needs. A thorough business continuity plan was in place with continency arrangements for emergencies including extreme weather, staff disruption and electric/other supply issues. The business continuity plan was easily accessible to staff and the management team.

Staff and the registered manager were clear about their roles and responsibilities. The registered manager submitted statutory notifications to CQC. The registered manager told us they had full oversight over accidents, incidents and safeguarding concerns and they went out on the floor of the home on a daily basis to undertake checks. One staff member told us "The registered manager walks round a lot, they are visible. The deputy manager is always working on the floor with us." The registered manager told us they checked on each floor at the end of the day to see if there had been any accidents, incidents and safeguarding concerns and reported a daily summary to the provider as an extra level of oversight The registered manager they undertook higher level analysis to identify trends for risks such as falls and low fluid intake. The registered manager told us they had acted on this feedback where they identified there had been a pattern where people had fallen when they had low fluid intake by introducing days where the focus was on fluid intake and hydration such as Milkshake Mondays. The registered manager also told us they had identified another trend where when they had had Covid outbreaks, incidents had increased. As a result, they introduced an 'outbreak pack' which enabled people to do more activities in their rooms. The registered manager told us that the provider also undertook 3 monthly audits on top of their checks to add an extra level of oversight. Staff told us the governance at the home was positive. Staff told us they had in depth handovers which they felt were valuable and enabled them to highlight any concerns and also share information regarding the previous shift. Staff told us the registered manager and deputy manager were responsive in dealing with any concerns raised and actioned any issues immediately. Staff corroborated that where management undertook daily checks, they fed back in handovers if anything required addressing.

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.

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