Waterbeach Lodge

Updated 28 January 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 included checking the provider was meeting COVID-19 vaccination requirements. 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

This inspection was carried out by two inspectors.

Service and service type

Waterbeach Lodge is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. 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. The registered manager was not available during this inspection.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and safeguarding team who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke to three people about the care provided. We also spoke with seven staff members. We spoke with the director of care and the compliance manager who were overseeing the service in the registered managers absence. We also spoke with two senior care staff, a care staff member, and agency staff member and a housekeeper.

We reviewed a range of records. This included two people’s care records and medication records. We looked at two staff files in relation to recruitment and vaccination status. We also looked at a variety of records relating to the management of the service, including staff rotas, surveys, meeting minutes, accidents and incidents analysis and safeguarding were reviewed.

Updated 28 January 2022

About the service

Waterbeach Lodge is a residential care home providing accommodation and personal care to 27 people at the time of the inspection. The care home can accommodate up to 46 people across three separate floors. One of the floors specialises in providing care to people living with dementia.

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

Staff had improved their infection prevention and control practices in line with government guidance since the last inspection. This would help reduce the risk of cross contamination within the service.

There was organisational oversight within the service to support staff and again, this had improved since the last inspection.

Staff knew the people they supported well and demonstrated how they would use this knowledge when assisting people. There were enough suitably trained and knowledgeable staff to help support people in a timely manner. Potential new staff to the service had a series of checks carried out on them to try to make sure they were suitable to work with the people they supported.

Staff demonstrated a good understanding of how to report safeguarding concerns. Risk assessments to guide staff on how to monitor people’s individual risks were in place and updated. Staff supported people to take their prescribed medicines safely. Lessons were learnt and shared with staff when improvements were needed to help reduce the risk of incidents recurring.

Staff worked with external health professionals. This helped make sure people received joined up care and support. People and their relatives were asked to complete surveys to feedback on the service provided by staff. Suggested improvements were acted upon wherever possible.

Audits were undertaken to monitor the quality of the service provided. There was an unannounced provider audit also undertaken to promote organisational oversight of the service.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 04 March 2021) and there were breaches of regulation found. The breaches were Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People were not protected from the risk of harm caused by poor infection prevention and control measures. We also found a breach in relation to Regulation 17 (Good governance) of the Health and Social Care Act (Regulated Activities) Regulations 2014. The service had been impacted by COVID-19 and there was a lack of organisational oversight at the time.

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulation.

Why we inspected

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions safe and well-led which contain those requirements. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Waterbeach Lodge on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.