Waverley Lodge

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

The service was well-led and has been rated good. The management team and staff had worked together to drive improvements since the last inspection. Effective governance systems were being used and embedded to identify shortfalls. Robust action plans were in place and not signed off as completed until processes were fully embedded and sustained. The staff team were well motivated and worked well together to embed improvements, some of which were ongoing.

This service scored 64 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff were positive about the culture. Comments included, “It’s really good at the minute, it’s improved since the regional managers been here. It’s a really good team.” Other comments included, “Staff are happy, residents are happy, I enjoy coming to work again now” and “It’s a lovely place to work.”

Processes were in place which enabled the quality manager to work alongside the staff team to coach, mentor and role model good care. This supported a shared understanding within the team and promoted a positive culture of working together, to ensure good quality care and support.

Staff were positive about the leadership of the regional manager. Comments included, “She’s got so much done in a short time. I raised concerns about someone, as I was concerned about the bath, and they got a safe chair so they could shower safely.” Staff also commented about the management team being visible, supportive, open, and honest.

A system of role modelling and coaching had been implemented. The quality manager and regional manager worked alongside staff to develop their confidence and increase their knowledge. This led to staff feeling valued and motivated to improve and develop the quality of care people received. The quality manager said, “It’s about finding resolutions together, understanding what we expect and how we can achieve it together. Staff confidence and self-esteem has progressed.” The regional manager said, “The staff team have worked really hard and I’m extremely proud of them.”

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.

Staff understood their role and responsibilities. One staff member said, “Im expected to give quality care, and have a duty of care to all residents to ensure dignity and respect.” Another said they tried to, “Ensure residents are happy, safe and well cared for.” Some staff were involved in audits and explained the importance of being transparent, honest, and professional at all times.

At the last inspection, an effective system to monitor the quality and safety of the service was not in place. The regional manager had worked to embed robust quality assurance measures, which included oversight and verification of audits and actions. A quality lead had been appointed. They were supporting the staff team alongside the regional manager in the absence of a registered manager. A new manager was due to start in January 2025. A significant number of improvements had been made, and work was ongoing to ensure identified shortfalls were addressed and improvements embedded and sustained.

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.

There was a clear focus on learning together to improve the service. Visiting professionals were positive about improvements that had been made. Comments included, “There was a safeguarding raised and the staff worked with the professionals to get the best outcome for the person.” Another said, “We were happy with how the issues we highlighted were managed, there was additional training, and we worked together well.”

Processes were in place to ensure robust oversight of the quality of the care and support people received. Widespread improvements had been made, including to processes, oversight and staff support and training. There was a clear commitment from the whole team to increase their skills and knowledge to ensure people received safe care. There was a focus on learning, and the regional manager was aware improvements were still ongoing, including the need to ensure sustainability and embedding of oversight and quality assurance systems.