Waverley Lodge

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

The service was safe and has been rated good. Improvements had been made since the last inspection and staff had a good understanding of how to safeguard people from harm and abuse. Staff involved people in the management of risks and supported their safety. Safe recruitment practices were followed, and agency staff were assessed for their suitability to meet people’s needs. Ongoing improvements to the safe management of medicines were in progress and being embedded.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and their relatives were happy with staff and the care they received. People knew how to raise complaints. One person said, “I’ve had no reason to complain” and another said, “Any complaints have been well managed."

Staff spoke of a positive culture, giving examples of increased training when they had said they weren’t comfortable using some specific equipment. The regional manager and quality manager were very focused on learning and involving staff in their own development. They gave specific examples where procedures had been improved, including the importance of face-to-face pre-admission assessments.

Processes had been implemented to develop staff confidence and self-esteem, alongside supporting them to learn from safeguarding concerns, complaints, audits and accidents and incidents. Notifiable safety incidents had been identified and Duty of Candour requirements had now been met.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us they felt safe. Relatives said they would approach the current management team about any concerns, commenting, “They are very approachable.”

Staff were aware of the action they would need to take if they had a safeguarding concern and were confident the current management team would take appropriate action. Staff said they had attended training in safeguarding, mental capacity and DoLS (Deprivation of Liberty Safeguards).

We did not observe any concerns of a safeguarding nature during the assessment. Staff attended to people’s needs in a timely manner and responded to any risks with a proactive and sensitive approach.

An effective safeguarding system had been implemented and records now evidenced appropriate identification, reporting and investigation of concerns. Visiting professionals told us about a safeguarding concern they had raised, saying they were confident in how it had been managed and the learning that followed, including additional training for the staff.

People, and their relatives said they were involved in their care and kept up to date if any changes were made.

Staff said people were involved in making decisions about their care. One staff member said, “If there is a particular risk for residents this is noted in their care plan. For example, if they were at risk of falls or falling out of bed, they can then access the necessary equipment.”

We observed staff supporting people in a safe and caring manner. We saw one incident of poor moving and handling practice. However, a staff member immediately explained how this was incorrect. The moving and handling instructor then followed this up with the staff who were involved.

An effective system to assess and monitor risks was now in place, which included an indication of whether people had been involved in assessments. Review dates were set, and staff were aware that if people’s needs changed, they needed to report this so risk assessments and care plans could be reviewed and updated.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

People and relatives said there were enough staff. Some relatives commented staff were very busy but always there if needed.

Overall, staff commented there were enough staff. One staff member commented about some pressures at mealtimes. We raised this with the regional manager who said they were aware of the concerns and would look into it.

We observed safe staffing levels. Staff were visible and accessible to people, responding to their needs in a timely and respectful manner.

Safe recruitment practices were followed. New staff had an induction to the service and were provided with a handbook which contained key information. Procedures for assessing the suitability of agency staff had improved. Agency staff profiles were reviewed to make sure they were suitable, and inductions were completed.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

Records demonstrated that people were receiving their regular oral medicines as prescribed. Care plans were in place. However, some required further development to ensure they captured people’s specific needs. For example, for people with diabetes. On our second visit the regional manager had actioned our concerns. However, not all care plans we looked at had been updated. Following the inspection the regional manager sent a further example of how care plans would be rewritten; the example shown demonstrated a personal approach and easy to follow guidance for staff. Guidance to support staff in the administration of ‘when required’ medicines needed improvement. We found protocols to be generic and not specific to that person. The regional manager told us they were working to improve this and post inspection provided examples of how they had been improved.

Staff training and medicines competencies were being monitored on a new electronic system, and we saw evidence that they were being assessed on an ongoing basis. The service currently had no registered manager, and oversight was being provided by the regional management team. Provider audits had taken place in October 2024 which had identified a number of the issues we noted. Some of the actions had been implemented and the regional management team were working through the identified actions. During and post the inspection the regional manager had continued to make improvements in the service. Until these were fully embedded, we could not measure the full effect of these changes.

Medicines were stored securely and safely with the appropriate temperature monitoring taking place. Guidance was in place to support staff in the administration of thickening agents (medicine used to thicken food or fluid for those with swallowing difficulties). Some records demonstrated thickener had not been added or had been added incorrectly. We were reassured this was a recording issue as all staff we spoke with knew tpeople's thickener requirements. Topical medicines were recorded as administered on an electronic system. However, the records on this system did not always demonstrate which prescribed creams had been applied and to which location. Therefore, we could not be assured that people were receiving their creams as prescribed.