The Care Quality Commission
  • Mental Health
  • Independent mental health service

Waterloo Manor Independent Hospital

Overall: Good read more about inspection ratings

Selby Road, Garforth, Leeds, West Yorkshire, LS25 1NA (0113) 287 6660

Provided and run by:
Waterloo Manor Limited

All Inspections

During an assessment of Forensic inpatient or secure wards

Date of assessment 14th May to 4th June 2024.

Waterloo Manor Independent Hospital provides forensic services for up to 25 women. There are two low secure wards:

• Cedar - 12 beds

• Maple - 13 beds

At the time of our assessment there were 13 patients admitted to Maple and 2 patients admitted to Cedar.

The service had made improvements and was no longer in breach of regulations. Premises were now clean, the wards had been decorated, furniture had been replaced, and the seclusion room was now clean and fit for purpose. Defibrillators were now regularly serviced and safe to use. Care plans now reflected the physical health needs of patients. Governance processes were now effective.

People were protected and kept safe. Staff understood and managed risks. Managers made sure staff received training to maintain high-quality care. Staff managed medicines well and involved people in planning any changes. However, patients and staff told us that some staff from overseas had limited use of English which caused communication challenges.

People were involved in assessments of their needs. Care took account of people’s communication, personal and health needs. Staff worked with all agencies involved in people’s care for the best outcomes. They monitored people’s health to support healthy living. However, not all staff had a good understanding of the Mental Capacity Act 2005.

People were treated with kindness and compassion. Staff treated them as individuals and supported their preferences. People had choice in their care and were encouraged to maintain relationships with family and friends.

People were involved in decisions about their care. People received fair and equal care and treatment. Leaders were visible, knowledgeable and supportive. Staff felt they were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities.

During an assessment of Long stay or rehabilitation mental health wards for working age adults

Date of assessment 14th May to 4th June 2024.

Waterloo Manor Independent Hospital provides rehabilitation services for up to 31 women across 4 wards.

An assessment has been undertaken of a service that is used by autistic people or people with a learning disability but is not registered as a specialist service. We have assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. The assessment did not raise any concerns.

The service had made improvements and was no longer in breach of regulations found at the last inspection. Premises were now clean, the wards had been decorated, furniture had been replaced, and the seclusion room was now clean and fit for purpose. Governance processes were now effective.

People were protected and kept safe. Staff understood and managed risks. Staff managed medicines well and involved people in planning any changes. Care was based on latest evidence and good practice. People were treated with kindness and compassion. People received fair and equal care and treatment.

However, patients and staff told us that some staff from overseas had limited use of English which caused communication challenges. Visits from relatives happened in the main hospital building rather than on individual wards. This was a blanket restriction.

We found one breach of the legal regulations in relation to person-centred care.

We have asked the provider for an action plan in response to the concerns found at this assessment.

During an assessment of the hospital overall

Date of assessment 14th May to 4th June 2024.

Waterloo Manor Independent Hospital is an independent hospital for up to 56 women who have a mental illness and/or personality disorder. Some of the women may have a learning disability in addition to a mental illness. Most patients are detained under the Mental Health Act 1983. Some patients within the rehabilitation service are there voluntarily.

There were 25 forensic/low secure beds across two wards:

• Cedar - 12 bed low secure ward primarily for women with a diagnosis of personality disorder

• Maple - 13 bed low secure ward primarily for women with a mental illness.

There were 22 rehabilitation beds across two wards:

• Larch – 8 bed high-dependency rehabilitation ward primarily for women with a diagnosis of personality disorder

• Hazel – 14 bed locked rehabilitation ward for patients with a diagnosis of personality disorder and/or mental illness.

There are a further 9 beds that offer less restrictions and semi-independent living:

• Lilac – 5 beds

• Holly – 4 beds (annexed to Hazel ward)

Waterloo Manor Independent Hospital has been registered with the Care Quality Commission since 2011. It is provided by Waterloo Manor Limited, which are part of the Inmind Healthcare Group. The service had a registered manager at the time of our assessment.

The service was last inspected by the Care Quality Commission in March 2022. It was rated as requires improvement overall, and for each service. There were five breaches of regulation in the forensic service and three breaches of regulation in the rehabilitation service. These breaches had all been met. However, at this assessment we found the rehabilitation service was in breach of regulations in relation to person centred care.

22 March 2022 23 March 2022

During a routine inspection

Our rating of this location stayed the same. We rated it as requires improvement because:

  • The ward environments were not always safe or clean and staff were not always following guidance in relation to infection control.
  • The premises did not always promote privacy and dignity for all patients.
  • Staff on Cedar and Maple wards did not consistently assess and manage risk well.
  • Although staff engaged in clinical audit to evaluate the quality of care they provided, audits were not always effective in identifying issues.
  • Not all checks following rapid tranquilisation were accurately recorded on Cedar ward.
  • Not all care plans on Maple ward were comprehensive.
  • Care plans did not accurately reflect the assessed physical health needs of all patients
  • Staff did not always understand and discharge their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Not all staff had received up to date supervision or had access to regular team meetings.
  • Our findings from the other key questions demonstrated that governance processes did not always operate effectively at team level and that performance and risk were not always managed well.
  • Staff did not always feel respected or valued.

However:

  • The wards had enough nurses and doctors. They minimised the use of restrictive practices and followed good practice with respect to safeguarding.
  • In the main staff developed recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training and appraisals.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.

20-21 April 2021

During an inspection looking at part of the service

Our rating of this location went down. We rated it as requires improvement because:

  • The service was not always well led, and the governance processes did not always ensure that ward procedures ran smoothly.
  • The service did not always minimise the use of restrictive practices or follow good practice with respect to safeguarding.
  • The wards did not always have enough nurses, support workers and allied health professionals.
  • Staff did not always receive timely training, supervision and appraisal.

However

  • The service provided safe care. Staff assessed and managed risk well. The service had enough doctors.
  • Staff developed recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. The ward staff worked well together as a multidisciplinary team.

This was a focused inspection. Because of its limited scope, we did not set out to rate at this inspection. However, where we have identified a breach of a regulation and we issue a requirement notice, the rating linked to the area of the breach will normally be limited to ‘requires improvement’ at best. This has not changed the overall rating of ‘safe’ which remains as requires improvement; the overall rating of ‘well led’ has changed from good to requires improvement. You can view previous ratings and reports on our website at www.cqc.org.uk.

19-22 February 2018

During a routine inspection

We rated Waterloo Manor Independent Hospital as good because:

  • Staff had ensured that patients were fully involved as partners in their care. Feedback from patients about staff attitudes and behaviours was highly positive. Carers were positive about the hospital and told us that they felt appropriately involved in the care delivered by the hospital. Staff supported patients well and encouraged patient led initiatives and events.
  • Environmental risks and individual patient risks were assessed and appropriate management plans were in place. Premises and equipment were clean and well looked after. Medications were managed well. Staff understood how to recognise, report and protect patients from abuse. Staff learned from incidents and worked to prevent incidents from happening again.
  • There were clear admission criteria. Average lengths of stay were less than national averages for similar services. There was a range of activities available including a fully established and embedded recovery college. Complaints were responded to quickly and appropriately.
  • The hospital was well-led. Managers and staff had worked to improve the culture of the hospital since the previous inspection. Managers were visible in the service. There were effective systems in place to ensure good governance. Key performance indicators were effectively used to monitor the service and make improvements. There was a clear commitment to improving the service from all staff.

However,

  • There were not enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. Lilac ward did not have a qualified nurse working on the ward to provide the right care and treatment.
  • Staff were not always recording the level of consciousness of patients following the administration of rapid tranquilisation in line with the hospital policy.
  • We found two patients on Maple ward had been administered medication which were not included on the relevant consent to treatment documentation.
  • Whilst the hospital had recently introduced a new system for monitoring supervision, staff were not maintaining detailed records of supervision sessions.

01 March 2017

During an inspection looking at part of the service

We rated Waterloo Manor Independent Hospital as requires improvement overall because:

At this inspection, we found areas of concern in the safe and well-led domains.

  • The provider had not risk assessed the impact on the patient environment and the patients where a boiler had broken and patients’ did not have access to hot water, or find alternative washing facilities.
  • Some patient records were incomplete, including observation records and medication records, and documentation and storage of that documentation was inconsistent and not always in line with guidance provided.
  • Not all systems and processes in place to ensure patients were safe and that treatment and care was effective were robust or effective. This included systems to ensure that accurate and complete records were maintained, cleaning schedules were completed, and contingency plans were in place.

However,

  • During this most recent inspection, we found that the service had addressed the breach of regulation that had caused us to rate safe as requires improvement following the June 2016 inspection. All the wards were clean at the time of this inspection.
  • Waterloo Manor was now meeting Regulations 15 of the Health and Social Care Act (Regulated Activities) Regulations 2014.
  • Following our inspection in June 2016, we rated the location as good for effective, caring and responsive. Since that inspection we have received no information that would cause us to re-inspect these key questions or change these ratings.
  • Staffing levels across the hospital were adequate and ensured patient need was met. Recruitment was ongoing and the hospital continued to use bank and agency staff to fill any staffing shortfalls.
  • The level of engagement and involvement of patients with regional involvement groups and the recovery college was encouraged and supported by staff. Patients attended meetings and contributed positively to projects within the hospital.
  • Staff gave positive feedback about the management of the hospital. They said there had been some changes since our last inspection which they felt were positive. They told us management were approachable and they felt able to raise issues and concerns.

27 - 29 June 2016

During a routine inspection

We rated Waterloo Manor Independent Hospital as good because:

Patient involvement within the hospital is well-embedded, with two staff involvement leads. Patients are involved at all levels within the hospital and attend Yorkshire and Humber regional involvement meetings.

Patients told us they were happy with the care they received at the hospital and spoke highly of staff. They said staff were respectful towards them and encouraged them to participate in activities. All patients were assessed by the occupational therapist, and had at least 25 hours of planned activity per week. This was reviewed weekly by staff at ward level.

Patients had access to well maintained outside space. On all of the ward areas, notice boards displayed information on involvement, activities and advocacy. Patients told us they valued the advocacy services which were available to both detained and informal patients.

Staff demonstrated a good understanding of safeguarding. Systems were in place to ensure that medicines were managed safely. Staffing levels across the hospital were adequate to meet the needs of the patients. The ward managers told us that they were able to increase staffing levels when there was an increase in the needs of the patients. Staffing levels were often maintained using bank and agency staff. Overall compliance with mandatory training was 93%.

Staff told us that blanket restrictions may be implemented for short periods of time but were reviewed. Staff showed a good understanding of the Mental Health Act code of practice and guiding principles. Mental Health Act and Mental Capacity Act principles were adhered to.

Prior to admission, each patient had an extensive multidisciplinary care plan developed, this identified patient needs, treatment options and goals. On admission, each patient was assessed, including a physical health examination. We found care records contained care plans which were person centred and showed evidence of involvement of the patient.

Menus showed a range of options were available for patients including vegetarian, healthy eating and halal diet. The chef attended weekly community meetings on the wards to keep up to date with any requests or queries from patients.

Staff told us that the culture at the hospital had changed in the last 12 months and they felt supported and valued. Staff survey results were positive. A ‘lessons learnt’ log was in place to review themes and trends of incidents. Complaints were investigated as per policy.

The provider had a specific policy for the duty of candour. The policy included an obligation to inform following a serious incident or near miss and included a specific undertaking for the service to apologise following incidents. Staff demonstrated an understanding of the principles of duty of candour.

However:

  • Overall, wards were clean and the environment was well maintained. However, on Maple ward we found several areas that were unclean.
  • Staff did not have training on how to meet the needs of patients with a diagnosis of personality disorder.
  • Patients with bedroom windows which face the courtyard areas tended to keep their curtains closed to ensure that privacy and dignity are maintained.
  • There were a number of blind spots in the hospital, such as bedrooms corridors, where action needed to be taken to mitigate this.
  • There was limited provision of therapeutic groups within the hospital.
  • Supervision and appraisal rates for staff were not consistent throughout the hospital.
  • The hospital did not participate in national service accreditation or peer review schemes.

19, 20 and 21 August 2015

During an inspection looking at part of the service

We inspected Waterloo Manor Independent Hospital, but did not provide a rating. This was a focused re-inspection and, therefore, not all of the key lines of enquiry were inspected, as not all were relevant to the areas identified for the re-inspection, the review of the warning notices and the requirement notice.

We inspected the service in February 2015 when the service was rated inadequate because it was failing to meet regulatory standards in all areas inspected. We issued four warning notices, informing the service that they must meet the required standards by 9 July 2015 and advised that failure to do so would result in further action being taken.

We also issued one requirement notice in relation to safeguarding patients from abuse. We told the provider to tell us how improvements would be made. The service sent us an action plan detailing how improvements would be made.

When we inspected the hospital in August 2015, we looked at how the service was making progress in meeting the standards. We reviewed the action plan provided to us following the last inspection and we found that the service had made significant improvements to ensure patients received a standard of care that did not place them at risk of harm. We were satisfied that the requirements set out in our warning notices had been met and that the service was improving its systems for identifying and preventing concerns of abuse.

During our inspection, there were 39 inpatients at the hospital. Following our inspection in February 2015 the service had made a voluntary agreement with the Care Quality Commission that no further admissions would take place until significant improvements had been made. We looked in detail at how the service had improved and identified which steps had been taken to address the following areas:

  • Safe and clean environments.
  • Ensuring patients were protected from the risks of abuse.
  • Ensuring staff were deployed correctly and there was sufficient skilled staff to meet patients’ needs.
  • Patients’ risks were appropriately assessed and care and treatment was planned and delivered in accordance with the assessed needs of individuals.
  • Patients received care which was evidence based and fully integrated through an effective multi-disciplinary team (MDT). Where physical health care issues were identified these were effectively monitored with input from relevant professionals.
  • All patients we reviewed had a discharge plan in place to ensure their needs when leaving the service would be met.
  • The service had clear visions and values and, although these were in their infancy, the service recognised it still had work to do to ensure improvements continued and were sustained.
  • The culture had improved with staff and senior managers talking positively about each other, and the changes which had been implemented.

Since our inspection in February 2015, all senior managers had left the service and a new team had been appointed. There was a new clinical director, a new head of occupational therapy, new head of psychology and a new governance director. There were also new appointments of nursing staff. However, the service did not have a registered manager, which is a legal requirement under the Health and Social Care Act 2008. Although at the time of the inspection the service did not have a registered manager, the recruitment process to appoint a Hospital director for this service was in place.

11,12,19,20 February 2015

During a routine inspection

We rated Waterloo Manor Independent Hospital as  Inadequate :

Patients were cared for in unsuitable environments that compromised their health and well-being. Dirty wards with tired furnishings were not conducive to patients' recovery.

Managers had no plan to reduce the number of fixtures on the ward that could be used by patients to tie a ligature. Also no action was taken to reduce the risk to patients with suicidal thoughts and behaviours.

Staff did not maintain comprehensive risk assessments .

Staff did not manage medication safely and no action was taken on reports from external agencies with a monitoring role to oversee audit and safe practices in relation to medication.

The senior management team did not ensure that learning from serious incidents was always shared with front-line staff. This meant that these staff members did not always benefit from learning the lessons of investigations into incidents, meaning poor or unsafe practices could be repeated.

Staff did not plan, assess, or provide care to an adequate standard. For example, they did not seek the advice of professionals where patients’ physical health care needs were potentially compromised, particularly in relation to nutrition, weight management, and healthy life choices.

Patients were transferred from one ward to another during their admission without proper planning or communication. This affected the continuity of care and increased the possibility of making mistakes because historical information, care planning, and relationships between key workers and patients were disrupted.

Staff did not demonstrate a good understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). When staff did assess the mental capacity of a patient to consent to care, their assessment was often not thorough enough.

The overall leadership and management of wards was poor. There were limited systems to audit the quality of care or to listen to patients' concerns and complaints, and insufficient action was taken to improve the overall quality of care.

The service had an improvement plan, developed since the previous Care Quality Commission inspection, but the senior management team did not monitor this closely enough and key actions were not carried out. Staff were not clear when or how improvements were taking place, this meant that improvements to the service were not happening quickly enough.

The senior management team had looked for reassurance on progress in the hospital since the last inspection rather than seeking assurance and taking control and responsibility for the areas of non compliance which had been identified.

Professor Sir Mike Richards

Chief Inspector of Hospitals

6, 7 January 2014

During a routine inspection

We learnt that the hospital had been finalists in the Innovation in Health Care Awards, and new approaches to the treatment of patients who had a personality disorder were being introduced.

We found a range of assessments had been carried out but equally found care plans were not always in place for identified needs. Some care plan reviews were being carried out on an infrequent basis and appeared quite superficial in nature. We received mixed feedback from patients regarding Waterloo Manor. One patient told us: "[Waterloo Manor] is the best hospital I've been to" whilst a different patient told us: 'I hate it here, [there's] lots of people kicking off all the time. We equally received mixed feedback from staff we spoke with regarding the care provided at the hospital. Not all staff members felt able to recommend the hospital to a family member of friend. We found best practise, regarding the carrying out of physical observations after certain medicines had been given, was not being followed.

We found safeguarding training had been provided to staff but saw this had expired for several staff members. Some concerns had been raised with us regarding the apparent frequent use of physical restraint of patients, particularly on Cedar Ward. Whilst we found no evidence to substantiate this, we found incidents of restraint were not always being properly reported as incidents. This meant hospital managers were unable to quantify the frequency in which restraint actually took place. We saw that for patients who were quite insistent on receiving certain medications by means of injection, there were no care plans in place to try and address this and reduce the risk of dependency developing.

Some staff and patients raised concerns with us about some staff allegedly sleeping on duty, at night. We saw evidence which confirmed the hospital management was aware of these concerns and were taking steps to address them.

We found controlled drugs were being stored correctly. Temperature monitoring for medications was also being carried out. We found some medications were out of date, and in some cases patients had gone without medicines because the supply had run out.

We found evidence of appropriate recruitment procedures being followed, and checks being carried out on staff. We found new staff received an induction which was generally felt to be good.

We found evidence of insufficient staff support by means of inadequate supervision and appraisals. Several staff raised concerns with us about feeling unsupported because of what they considered to be insufficient staffing levels.

Whilst a framework for record keeping was in place, we found some evidence of poor records management.

The hospital has started to act upon our initial feedback and inspection findings in order to bring about improvements. An initial plan has already been received by the Commission to address some of the issues identified.

It should be noted that in this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

23 October 2012

During a routine inspection

We spoke with three patients who told us they knew about the care and support that was planned for them and said they were consulted about this. They also told us they attended meetings to review their care plan and progress and were given the opportunity to share their own views about this.

Patients told us they were kept informed about the planned changes for the future service delivery at Waterloo Manor.

One patient said; 'I like it a lot here. I get chance to go out and can now use public transport. Staff listen and generally care about your mental heath. Staff are very friendly and approachable and we have a laugh. I have not found this in other places where I have been.' Another patient said; 'Staff are very helpful, especially the manager.'

Another patient told us the food was 'fantastic' and they had the opportunity to have takeaway meals each week.

Patients were able to explain why they were taking certain medications and said that the medical team had explained to them about the possible side-effects from the medication prescribed and had sought their consent about taking the treatment.

Each patient spoken with said that there had never been any shortfalls in staffing levels that had resulted in cancellation of their section 17 leave.

Patients spoken with told us they felt able to make comments or complaints and believed they would be listened to and their concerns acted on, without the fear that they would be discriminated against for making a complaint.

One patient told us, 'I think it is alright here. I am relaxed and know if I have any concerns I can go to the staff.

1 November 2011

During a routine inspection

Patients told us that staff explain and discuss their care with them. A patient explained how they had been involved in discussion about staff interventions they preferred to be used if their behaviour put themselves or others at risk.

One patient said, 'We are asked for our opinions and views and have a say in how the hospital can be improved.' Another patient explained their involvement with independent advocacy services.

All of the patients in Waterloo Manor are detained under the Mental Health Act 1983. Patients spoken with told us that staff had fully explained their rights in relation to their detention.

Both patients we spoke with were complimentary about the care they receive. One patient told us 'The staff are excellent.' Another patient said that staff are 'helpful.'

One patient told us 'I was very unwell when I came here and without the staff I do not think I would be here today.'

Patients told us that they feel safe at Waterloo Manor and had confidence that any concerns would be properly dealt with. One patient said, 'I raised a concern in the past and was satisfied with the outcome from this.'

Patients provided mixed comments about staffing levels. One patient said that staff could be accessed at all times. However, another patient said that there can sometimes be problems in the early evening.

One patient said, 'Quite like it living here. The staff are friendly and have always got time for you.' Another patient explained that she was doing recovery work which would prepare her to live back into the community. A patient told us that she was writing her own report detailing how she was progressing. She was receiving staff support to help with this, and the report was to be presented to people attending her imminent MDT review.

During our visit we spoke with staff about the training they had done and looked at some training records.

All staff have completed mandatory training such as fire safety, first aid, infection control and safeguarding patients from abuse. Staff had also undertaken more specific training about resuscitation, the mental health act and managing violence and aggression. A member of staff told us 'The training is very good.' A training matrix is used to record when staff have completed training and when updates are needed so that staff are kept up to date with good practices.

Permanent members of staff have regular supervision that is recorded. However, there is currently no supervision system in place for non-permanent staff such as those who work as bank staff.

Patients told us that they are asked for their views and opinions about how the hospital is run and complete information about this.

Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.