Waverley Care Home

Updated 30 January 2024

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.

Inspection team

This inspection was carried out by two inspectors and an operations manager.

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

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager still registered with CQC. However, they had recently left employment with the service.

Notice of inspection

This inspection was unannounced.

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 and professionals who work with the service. 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.

We used all this information to plan our inspection.

During the inspection

We spoke with 4 members of staff, the deputy manager administrator and a professional who visited the service. We reviewed a range of records. This included 5 people's care records and multiple medication records. We looked at 3 recruitment records, and other records relating to the management of the service, including policies and procedures were reviewed.

Updated 30 January 2024

About the service

Waverley Care Home is a large 3 story building. The service supports people with nursing needs. The service is registered to accommodate up to 20 people. At the time of the inspection, there were 11 people living at the home.

People’s experience of the service and what we found

We found high level concerns with regards to the premises and the equipment. Most areas of the home required repairs and some areas potentially put people at risk of significant harm. Hot water temperatures in sinks in people’s rooms and bathrooms were running above the required temperature, and fixtures and fittings, such as curtains in bedrooms, and paintwork, was in a poor state of repair. The dining room was not being used for its intended purpose and was being used as a storeroom. This meant people only had access to one communal area.

There was limited oversight regarding any maintenance work. Actions issued from a legionella risk assessment in March 2023 had not been completed, and there was no one checking maintenance jobs had been reported or actioned. Some records required improvement, there was no organised system to track and monitor DoLS applications, which meant that we could not be sure if DoLs had been applied for appropriately for people. There was no incident and accident analysis taking place, which meant we could not always be certain mitigation had taken place as a result of incidents. Therefore, we could not be sure lessons had been learnt from shortfalls in care provision.

There had been some improvements since the last inspection in relation to clinical care plans and medication. The provider had also made some improvements in relation to fire safety and staffing at the home.

People were looked after and staff were observed to care for people. However, due to there being a lack of space, because the dining room was not being used for its intended purpose, the home felt institutionalised in its approach. The dining experience was poor and the food was not presented nicely and did not look appetising.

People were mostly supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. However, some records in relation to DoLS required improving.

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 Inadequate, published 15 December 2022. 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 the provider remained in breach of regulations.

Why we inspected

When we last inspected Waverley Care Home on 27 October and 1 November 2022 breaches of legal requirements were found. We also issued a warning notice. This inspection was undertaken to check whether they were now meeting the legal requirements and to follow up the warning notices. We undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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

Enforcement

We have identified breaches in relation to infection prevention control, premises and equipment, records and governance.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.