Archived: Waverley Lodge Care Home

Updated 3 December 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 17 August, 22 and 28 September 2016 and the first two days were unannounced. The inspection team consisted of an adult social care inspector and a pharmacist inspector who assisted at the inspection on 17 August 2016.

Before the inspection we reviewed the information we held about the service, including notifications. Notifications are changes, events or incidents the provider is legally obliged to send us within required timescales. Before the inspection, the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We contacted the local authority commissioners of the service.

During the inspection, we used a number of different methods to help us understand the experiences of people who lived in the home, including observations, speaking with people, interviewing staff and reviewing records. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We spoke with four people who used the service and three visitors. We spoke with the registered manager and eight members of staff, including six care workers the chef and an ancillary worker.

We looked at a sample of records including four people’s care plans and other associated documentation, medicine records, four staff files, which included staff training and supervision records, two staff member’s recruitment records, complaint, accident and incident records, policies and procedures, risk assessments and audit documents.

Updated 3 December 2016

We carried out an inspection of Waverley Lodge Care Home on17 August, 22 and 28 September 2016. The first and second days of the inspection were unannounced. We last inspected Waverley Lodge Care Home in January 2016 to follow up previously identified breaches of regulation. We found the service was not meeting the regulation regarding safe care and treatment. Other regulations in force at that time were being met.

Waverley Lodge is a care home providing accommodation with nursing and personal care for up to 45 people. The service is primarily for older people, including people with dementia.

The service had a registered manager in post. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run. The registered manager was present and assisted us during this inspection.

People told us they felt safe and were well cared for. Staff took steps to safeguard vulnerable adults from harm and promoted their human rights. Incidents were dealt with appropriately and referred on to the appropriate authorities, which helped to keep people safe.

The building was generally safe and mostly well maintained. A small number of maintenance items were identified and some bathing and shower facilities required refurbishment. The property was purpose built as a care home and further steps had been taken to make the building suitable for the people living there, including for people living with dementia. Additional signage and control measures were used to highlight and minimise potential hazards and orientate people to the building. Risks associated with the building and working practices were assessed and steps taken to reduce the likelihood of harm occurring. The home was clean throughout, although some inappropriate storage was evident in a sluice room. There was limited availability of moving and handling equipment.

We observed staff acted in a courteous, professional manner when supporting people. Further guidance was required to promote safe manual handling for some individuals. We observed most staff adhered to safe manual handling practices, but queried the use of under arm support when staff transferred people from lounge armchairs to wheel chairs.

We received mixed views regarding the adequacy of staffing levels. The provider had a robust system to ensure new staff were subject to thorough recruitment checks. Improvements had been made to the way medicines were managed although record keeping and audit arrangements required further work to ensure medicines could be well accounted for.

As Waverley Lodge Care Home is registered as a care home, CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. We found appropriate policies and procedures were in place and the registered manager was familiar with the processes involved in the application for DoLS. Arrangements were in place to assess people’s mental capacity and to identify if decisions needed to be taken on behalf of a person in their best interests. Where necessary, DoLS had been applied for, although further guidance was needed where people received their medicines covertly. We observed staff obtained people’s consent before providing care.

Staff had completed safety and care related training relevant to their role and the needs of people using the service. Further training was planned on a regular cycle to ensure their skills and knowledge were up to date. The majority of staff told us they were well supported by the registered manager. Formal supervision meetings were conducted and staff told us they could seek guidance and advice from the registered manager and nurses on duty. Staff performance was assessed and targets set for their on-going training and development.

People’s nutritional status was assessed and plans of care put in place. People’s health needs were identified and external professionals involved if necessary. This ensured people’s general medical needs were met promptly. People were provided with assistance to access healthcare services.

Staff displayed an attentive, caring and supportive attitude. We observed staff interacted positively with people. We saw that staff treated people with respect and explained clearly to us how people’s privacy, dignity and confidentiality were maintained.

Activities were offered within the home on a group and one to one basis. Visitors were able to come and go freely. The home had a variety of communal rooms and quiet spaces which enabled people to sit in company or enjoy a quieter atmosphere. Staff understood the needs of people and we saw care plans and associated documentation were clear, up to date and person centred.

People using the service and most staff spoke well of the registered manager and they felt the service had good leadership. Some staff felt arrangements to rotate staff into different units in the home could have been more effectively managed. We fed back these comments to the registered manager. People using the service, visitors and staff said they would recommend the home to family or friends. We found there were a range of systems to assess and monitor the quality of the service, which included feedback from people receiving care and others. Some areas requiring improvements had not been fully addressed or improvements had not been sustained when the registered manager was absent.

We made recommendations regarding assessing and determining safe staffing levels and activities.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, relating to governance (management) and safe care and treatment. You can see what action we told the provider to take at the back of the full version of this report.