Waverley

Updated 22 July 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

Two Inspectors carried out this inspection on site and a third inspector undertook telephone calls to relatives after the inspection.

Service and service type

Waverley is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

We inspected the service on 23 June 2022 and following this undertook phone calls to relatives and staff.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority team who work with the service. This information helps support our inspections. We used all this information to plan our inspection.

The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.

During the inspection

We spoke with nine people who used the service. We spoke with three relatives about their experience of the care provided. All the people we spoke with were able to verbally communicate with us.

We spoke with seven members of staff including the registered manager, a senior support worker and five support workers.

We reviewed a range of records. This included three people’s care records and ten medication records. We looked at four staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the registered manager to validate evidence found. We looked at training data and quality assurance records.

Updated 22 July 2022

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

About the service

Waverley is a residential care home providing personal and nursing care to ten people at the time of the inspection. The service can support up to 14 people.

People’s experience of using this service and what we found

Right Support

Where decisions had been made for people who lacked capacity to make specific decisions, there was a lack of documented consultation with relevant family members, social workers or advocates. However, the service supported people to have choice, be independent and have control over their own lives.

People’s strengths were promoted and there was a focus on what they could do, so people had a fulfilling and meaningful everyday life.

Staff enabled people to access specialist health and social care support in the community.

Right Care

Some people’s care plans had not been reviewed to ensure they still reflected people’s needs. This short fall had not been identified in the provider’s quality monitoring processes.

The principles of STOMP (stop over medicating people with learning difficulties) were not always followed.

The service had enough appropriately skilled staff to meet people’s needs. However, some aspects of staff training were not delivered by appropriately trained staff.

Staff promoted equality and diversity in their support for people. People received kind and compassionate care.

Staff protected and respected people’s privacy and dignity. They understood and responded to their individual needs.

People could communicate with staff and understand information given to them. This was because staff supported them consistently and understood their individual communication needs.

Right culture

People were supported by staff who knew how to protect them from potential abuse.

The systems and processes in place to identify, report and investigate safeguarding concerns were used effectively by the registered manager and his staff.

Staff ensured risks of a closed culture were minimised so that people received support based on transparency, respect and inclusivity.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

The last rating for this service was Good (published 27 February 2021).

Why we inspected

We undertook this inspection to assess that the service is applying the principles of Right support Right care Right culture. The inspection was prompted in part due to concerns received about allegations of abuse. A decision was made for us to inspect and examine those risks.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to risk management, medicines, consent to care and treatment, and leadership.

Follow up

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.