Waverley Lodge

Waverley Lodge is a nursing home which provides nursing and personal care for up to 45 people, including people living with dementia. Accommodation is provided over two floors. There were 35 people using the service at the time of our inspection.

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

An effective system to assess and monitor risk was not fully in place. Records relating to falls management and accidents and incidents did not always demonstrate that management oversight and analysis had taken place. Lessons learnt had not always been documented and observations following a fall had not always been recorded in line with the provider’s policy.

Improvements had been made in relation to the cleanliness of the home. Several staff had chosen to wear a mask at work. Care workers and visitors do not routinely need to wear a face mask unless required to do so by the provider’s risk assessment. We observed that Government guidance regarding the safe way to wear a mask was not always followed by these staff.

An effective safeguarding system was not fully in place. Staff had not always recognised certain allegations/events were potential safeguarding incidents and therefore, had not made the necessary referrals to the local authority safeguarding team. People told us they felt safe, this was confirmed by relatives. One relative said, “I feel he is safe. I am very happy that he is where he is and he is safe.”

Recruitment checks were carried out before permanent staff started work at the home. However, agency profiles were not fully available to evidence that appropriate checks had been completed to assess the suitability of agency staff to work in the home.

There were enough staff deployed to meet people’s needs. We observed positive interactions between people and staff.

There was a system in place to manage medicines. However, we identified shortfalls in relation to medicines records/guidance. Following our feedback, management staff told us that this had been addressed.

Whilst the home had been redecorated; further action was required to ensure the design and décor, including the outdoor space was ‘dementia friendly’ and supported people’s orientation around the home.

People were supported to maintain their hobbies and interests. Further activities and resources were being explored and identified, especially in relation to people living with dementia.

Records did not fully evidence that staff training and support was carried out in line with the provider’s policy and mandatory training/support and development requirements.

An effective system to monitor the quality and safety of the service was still not fully in place. We identified shortfalls relating to the safeguarding system, the management of falls, the use of PPE and the maintenance of records.

Management staff explained they were introducing a new electronic care management system which would be used to record, report and monitor all aspects of people’s care and support.

Records did not demonstrate how the provider was meeting their responsibilities under the duty of candour. The duty of candour regulation tells providers they must be open and transparent with people about their care and treatment, as well as with people acting on their behalf. It sets out some specific thing’s providers must do when something goes wrong with someone's care or treatment, including telling them what has happened, giving support, giving truthful information and apologising.

There was a cheerful atmosphere at the home. We received positive feedback about the caring nature of staff from people and relatives. One relative told us, “They get to know the residents and build a good rapport with them so they know the staff. The actual care staff are very caring, not just about their needs but them as individuals. They are very friendly and greet family members when they go in. They behave as if it is your family member’s home.”

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

Rating at last inspection

The last rating for this service was requires improvement (published 11 November 2022) and there were breaches of the regulations. 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 that whilst improvements had been made; further action was required and the provider remained in breach of the regulations.

This is the second time the service has been rated requires improvement.

Why we inspected

We carried out an unannounced focused inspection of this service in August/September 2022. Breaches of legal requirements were found in relation to safe care and treatment, person centred care and good governance. We also identified a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 (notification of other incidents). The provider completed an action plan after the last inspection to show what they would do and by when to improve.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. Prior to this inspection, we also received concerns in relation to the management of falls. Falls management was reviewed as part of this inspection.

This report covers our findings in relation to the key questions of safe, effective, responsive and well-led which contain those requirements. We used the rating awarded at the last comprehensive inspection for the caring key question to calculate the overall rating.

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.

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

Enforcement and Recommendations

We have identified 4 breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 during this inspection. These related to safe care and treatment, safeguarding people from abuse and improper treatment, duty of candour and good governance.

Please see the action we have told the provider to take at the end of this report. 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.

Follow up

We will request an action plan and meet with management staff and the provider to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Waverley Lodge is a nursing home which provides nursing and personal care for up to 45 people, including people living with dementia. Accommodation is provided over two floors. There were 36 people using the service at the time of our inspection.

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

An effective system to ensure, the maintenance, cleanliness and safety of the premises was not fully in place. Not all areas of the home were clean or well maintained. After our first visit to the home, action had been taken to improve the cleanliness of the home.

An effective system to ensure staff were effectively deployed to meet people’s emotional and social needs and ensure the home was clean was not fully in place. Staffing levels had increased; however, due to the impact of COVID-19 and staff leaving the sector, the use of agency staff had increased. Several staff told us that this had affected the skill mix of staff on duty. Social activities had not been carried out as planned. Management staff had already identified the issues around staff deployment and had introduced an allocation system to ensure staff, including agency staff were appropriately deployed. They also increased cleaning hours and new full time and part time activities coordinators had been recruited. We have made a recommendation that the provider keeps staff deployment under review.

Policies and procedures in relation to the Mental Capacity Act 2005 (MCA) and the MCA application procedures known as Deprivation of Liberty Safeguards (DoLS) had not always been followed by staff. Relevant DoLS applications had not always been submitted to the local authority in a timely manner.

The design and décor of the service including the outside area, did not fully meet people’s needs, especially the needs of people who were living with dementia. There was little in the environment to stimulate people’s interest. We have made a recommendation about this.

The provider had set mandatory targets for the completion of certain staff training. These targets had not always been met. Following our visits to the home, management staff informed us that training statistics had increased.

There was a complaints system in place. However, the complaints log was not fully up to date which meant it was not possible to see how many complaints had been received and if there were any trends or themes. We have made a recommendation about this.

Records were not fully available to demonstrate how the provider was meeting their responsibilities under the duty of candour. The duty of candour regulation tells providers they must be open and transparent with people about their care and treatment, as well as with people acting on their behalf. It sets out some specific things providers must do when something goes wrong with someone's care or treatment, including telling them what has happened, giving support, giving truthful information and apologising. We have made a recommendation about this.

The provider had not informed CQC of all notifiable events at the home. The submission of statutory notifications is a legal requirement and ensures CQC has oversight of all notifiable events to make sure that appropriate action had been taken.

An effective system to monitor the quality and safety of the service was not fully in place. We identified shortfalls relating to infection control, the maintenance of the building, MCA application processes, the provision of person-centred care and record keeping.

Despite the issues identified during the inspection, people and relatives spoke positively about the caring nature of staff. Comments included, "The staff are approachable, all the way through from the office to the carers" and "Whenever they come past my relative they ask how he’s doing, he seems to like them." This care was reflected in comments from staff. One staff member told us, “Our residents are our priority.”

The service was working with a charitable organisation with regards to falls prevention. There had also been visits from Newcastle United’s young people's academy and links had been made between Waverley Lodge and another of the provider’s care homes to facilitate friendships and activities.

Following our visits to the home, we asked the provider to send us an improvement plan which detailed the actions they had taken/were going to take in relation to the issues identified during our inspection. The provider responded and sent CQC a detailed improvement plan.

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

Rating at last inspection

The last rating for this service was good (published 17 July 2018).

Why we inspected

The inspection was prompted due to concerns received about people’ care and support, infection control and the maintenance of the building. A decision was made for us to inspect the key questions of safe and well-led and examine those risks.

When we inspected, we found there were issues around MCA application processes, the design and décor of the service, the assessment of people’s needs and meeting people’s social needs, so we widened the scope of the inspection to include the effective and responsive key questions.

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.

We used the rating awarded at the last inspection for the caring key question to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection. We have found evidence that the provider needs to make improvements. Please see the safe, effective, responsive and well led sections of this full report.

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

Enforcement and Recommendations

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 three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 during this inspection. These related to safe care and treatment, person centred care and good governance. We also identified a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 (notification of other incidents).

Please see the action we have told the provider to take at the end of this report. Full information about CQC's regulatory response in relation to Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 (notification of other incidents) is added to reports after any representations and appeals

have been concluded.

We have made recommendations in the safe, effective, responsive and well-led key questions in relation to staff deployment, the design/décor of the home and records relating to complaints and the duty of candour. Please see these sections for further details.

Follow up

We will request an action plan and meet with the manager and provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Waverley Lodge is a 'care home'. Waverley Lodge provides personal and nursing care and support for up to 45 people who require support with personal care, some of whom are living with dementia. There were 31 people living at Waverley Lodge at the time of inspection.

We found the following examples of good practice:

• Staffing levels were safe. Staff were well supported by the registered manager and provider and had worked hard to support those who had to take time off work to isolate. There had been limited agency usage, for the purpose of additional support for one person, and the agency staff had been included in the home’s testing programme.

• Staff wore PPE appropriately and received training and ongoing competence assessments to help them follow best practice.

• All visitors had to undergo a temperature check, a range of relevant questions, and were asked to sign in to the NHS contact tracing app. The registered manager had thought pro-actively about the implications of national guidance on visiting and had made a range of changes to the building to facilitate this, when guidance and restrictions allowed.

• The premises had been adapted where practicable to enable better social distancing for people and staff.

• The registered manager had worked well with external partners to ensure areas of good practice they developed were pro-actively shared to enable other services to better cope with the coronavirus pandemic.

Further information is in the detailed findings below.

We found the following examples of good practice:

• Relatives were sent information of what to expect when visiting people and were provided with PPE if needed. All visits were risk assessed and steps put in place to mitigate any identified risks. People met with their relatives outside the service in designated areas which were clearly marked out to follow social distancing principles. People were also supported to stay in contact with relatives via video chats and telephone calls to help reduce the risk of social isolation. There were set procedures in place for any visitors to the service which included a temperature check, handwashing and a COVID-19 assessment form.

• Social distancing was observed by staff and the service had placed furniture in a way which helped to maintain distancing between people in communal areas. Staff wore PPE at all times and there were no issues regarding the supply of these. There was clear guidance and information located around the service along with designated rooms for changing clothing, testing, handwashing and training.

• Staff and people had COVID-19 related risk assessments in place. The registered manager had worked with staff members who were at greater risk, to find safer ways of working.

•There was a designated infection prevention and control lead within the staff team who undertook additional training and checks to make sure all staff were following guidelines and following national guidance.

Further information is in the detailed findings below.

This was the first time we had inspected the service since it was registered on 17 May 2017.

Waverley Lodge is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Waverley Lodge provides personal and nursing care and support for up to 45 people who require support with personal care, some of whom are living with dementia. At the time of the inspection there were 38 people living there.

The service had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission 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.

People and their relatives told us people were safe living at the service. Staff had completed training in safeguarding people and the registered manager actively raised any safeguarding concerns with the local authority.

Risks to people’s safety and wellbeing were assessed and managed. Environmental risk assessments were also in place.

People’s medicines were administered in accordance with best practice and managed in a safe way. People received their medicines in a timely way and in line with prescribed instructions.

People and relatives told us there were enough staff to meet people’s needs. Staff were recruited in a safe way with all necessary checks carried out prior to their employment.

Staff received regular training, supervisions and annual appraisals to support them in their roles. They also received specialised training, specific to people’s needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People were supported to meet their nutritional needs and to access a range of health professionals. Information of healthcare intervention was included in care records and a GP routinely visited the service weekly.

People and relatives spoke highly of staff and felt the service was caring. Staff treated people with dignity and respect when supporting them with daily tasks.

People had access to Independent Mental Capacity Advocates (IMCAs) and independent advocacy services if they wished to receive support. Information related to services was on display in the home.

People’s physical, mental and social needs were assessed prior to them moving into the home. Care plans were personalised, detailed and reviewed regularly and included people’s personal preferences.

There was a range of activities available for people to enjoy in the home. People were also supported, where necessary, to access activities in the local community including going for walks and shopping.

There were audit systems in place to monitor the quality and safety of the service. The views of people and staff were sought by the registered manager via annual questionnaires. Information collected was analysed and any identified actions were carried out and reported back to people and staff.