Waterloo House Rest Home Limited

Waterloo House is a residential care home providing personal care to 40 people aged 65 and over. At the time of this inspection there were 36 people living there, some of whom were living with dementia.

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

People said they were very happy at this home and had many positive comments about the “lovely” staff. Relatives praised the caring and kind staff who made the home a friendly, welcoming place.

All the people and relatives we spoke with felt the home was safe and comfortable.

Medicines were now managed in a safe way and there were systems to check this continued. Risks to people’s health and safety were assessed and minimised.

There were enough staff to make sure people received care and support whenever they needed it.

Staff followed national guidelines to prevent the spread of infection and to make sure the home was hygienically clean.

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

People said the home was well-run. They said the registered manager and staff were “very approachable” and “lovely to talk to”. People said they could raise suggestions and felt “listened to”.

The management team and staff were open, approachable and supportive. Relatives and staff said the management team had made significant improvements in the home. The provider and registered manager expressed their commitment to continuous improvement 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 1 May 2019) and there was a breach of regulation 12 (safe care and treatment). 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 the provider 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. The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Waterloo House Rest Home Ltd on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

People’s experience of using this service:

People’s medicines had not always been well managed. The provider was reviewing their audits and checks as they had not always found the issues we had regarding medicines. Although some of their other checks had uncovered issues which had been addressed.

The service was homely, clean and tidy. Further updates were required to finish redecoration. Full use of all communal rooms and improvements to the garden area was still to complete. We made a recommendation regarding the use of the smoking room.

Risks to people had been minimised but when things had changed risks had not always been reassessed. People were protected from abuse by trained staff who would report any concerns. Accidents and incidents were recorded and monitored.

People and their relatives said that staff were kind and caring and went out of their way to help them if they could. The care delivered was person centred and people and their families were fully involved in decisions made. Plenty of activities were available and new ideas were being worked on.

A good selection of home cooked foods was available to meet people’s dietary requirements.

Complaints had been dealt with effectively, but some outcomes had not always been documented, this was to be addressed.

There was enough staff and safe recruitment procedures were followed. Staff were trained and supported.

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.

There had been recent changes in the management structure which relatives and staff told us were positive. Action plans for improvement were in place which showed what work had already taken place, but some further work was required.

We have identified one continued breach of the Health and Social Care Act (Regulated Activities) Regulations 2014 in connection with medicines management. Details of action we have asked the provider to take can be found at the end of this report.

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

Rating at last inspection: Requires Improvement (Report published on 29 August 2018).

Why we inspected: The inspection was a planned inspection based on the previous rating.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our inspection programme. If any concerning information is received we may inspect sooner.

We previously inspected Waterloo House Rest Home in May 2017, at which time the service was meeting all regulatory standards and rated good. The service was rated requires improvement at this inspection.

The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to a criminal investigation and as a result this inspection did not examine the circumstances of the incident.

However, the information shared with CQC about the incident indicated potential concerns about the management of risk and the accuracy of care planning documentation. This inspection examined those risks.

Waterloo House 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.

Waterloo House accommodates a maximum of 41 people across two floors. Nursing care is not provided. There were 36 people using the service at the time of our inspection, some of whom were living with dementia.

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

There was a lack of managerial oversight with a range of audits either not being completed or failing to identify longstanding areas of concern. We could not talk to the registered manager at the time of inspection. The deputy manager had a good knowledge of people’s care needs but did not have oversight of the management structures in place. The service was lacking direction and at risk of further deterioration due to this lack of direction.

The external consultancy firm who had been completing twice monthly visits had not identified the majority of the issues we saw on inspection.

There was a lack of analysis of when things went wrong in order to learn from these incidents and make improvements.

Risk assessments and care plans were often out of date or inaccurate, putting residents at risk. The fact that people received care from a well-established and knowledgeable care staff team meant they had not suffered significant impacts due to this lack of governance.

There were a number of instances of minor poor practice identified regarding medicines administration. These had never been identified or improved upon by the provider because there were inadequate auditing procedures in place.

Staff felt supported by their peers but staff meetings (and resident/relative meetings) had not happened for some time. There was insufficient staffing in place at the time of inspection to effectively meet people’s needs and ensure compliance with the regulations. A dependency tool had not identified the need for increased staffing despite people's needs becoming more complex.

There were sufficient cleaning staff on duty but their hours of work needed reviewing as care staff were responsible for maintain cleanliness of the premises from 2pm onwards, which had a further impact on their ability to meet people’s needs.

The service did not have an effective training matrix in place and training records demonstrated a lack of Mental Capacity Act/DoLs training. Likewise, ancillary staff such as cleaners and laundry staff would benefit from dementia awareness training. We have made a recommendation about this.

We could not be assured that people were always supported to have maximum choice and control of their lives in the least restrictive way possible because the relevant documentation was either not available or out of date.

There were adequate bathing and toileting facilities in place. Other areas of the building required improvement or were not properly utilised, such as a large lounge, the manager’s office, and the outdoor space. Some equipment, such as the hoist and the sling, needed updating.

Care plans were sometimes brief although most we reviewed contained sufficient evidence for staff to know people’s basic needs. Staff knowledge of people’s needs was good and there were well documented interactions with external healthcare professionals.

Staff supervisions and appraisals had previously taken place but these had fallen away in 2018.

People had a choice of meals and gave positive feedback about levels of choice and range of food. Mealtimes we somewhat task focussed due to the pressures on kitchen staff but people did enjoy the meals.

People who used the service, their relatives and external professionals gave consistently excellent feedback about staff attitudes, patience, and commitment towards all people who used the service. The provider however had not given staff adequate time or support to provide care in a sufficiently patient and personalised way.

There was a strong consensus of opinion that the efforts, knowledge and passion of staff were the single biggest reason relatives and professionals would recommend the service. At the time of inspection, this passion and effort was not being adequately supported by the systems, process and upkeep of the premises and equipment by the provider.

We received exceptional feedback regarding how well staff supported people at the end of their lives, in conjunction with district nurses.

People’s changing needs more generally were not always accurately documented. Monthly reviews of care plans were in place but these appeared limited and had not identified the need to more comprehensively review people’s care needs, for example if someone had been suffering a high number of falls and may need new equipment or a different care plan.

Activities provision was not effective as the activities coordinator was only scheduled to work in that area for 21 hours per week. This was insufficient given people’s needs. Furthermore, the activities coordinator regularly helped with care tasks, detracting from the amount of time they had to plan and deliver activities. Information regarding people's individualities, life histories and preferences were inconsistent and not always accurate. We have made a recommendation about this.

There was no evidence of the provider ensuring staff were aware of recent best practice and links with external agencies to ensure practice improvement was limited.

The culture remained one focussed on caring for people in a dignified, personalised way, but this was largely down to the passion of the care team and not the provider, who needed to make a range of improvements to service provision.

We have identified six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

This inspection took place on the 23 May 2017 and was unannounced. We previously inspected this service in July 2016 where we identified the service required improvement overall and was rated inadequate in the well-led domain. At that time, the provider was in breach of Regulation 12 of the Health and Social Care Regulations relating to the safety of the premises and of Regulation 17 relating to the governance and leadership of the service. We also issued the provider with a fixed penalty notice for failing to display their previous CQC performance rating.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate in any of the key questions. Therefore, this service is now out of Special Measures.

A registered manager was in post and this manager had not changed since our last inspection of the service. A registered manager is a person who has registered with the Care Quality Commission (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.

We looked at how the service had addressed the safety concerns with the premises. We saw significant improvements had been made and all of the major issues had been addressed with an extensive refurbishment programme including the replacement of defective or unsatisfactory equipment. The majority of people’s bedrooms had been redecorated and re-carpeted, with the rest planned for imminent completion. It was clear that checks to ensure the safety of the service had been completed relating to electric, gas, asbestos and legionella. Staff completed daily, weekly and monthly checks on the premises to ensure it was safe and well maintained.

Improvements had also been made with regards to the quality assurance system. The provider had supplied the Commission with a monthly health and safety audit and an action plan. We saw prompt action had been taken to address the concerns raised and any new issues which had arisen were now promptly attended to. Detailed audits to monitor cleanliness, infection control, maintenance, medicines and finances were in place and regularly monitored. We have rated the service 'Requires improvement' in the well-led domain because we want to be assured that these improvements will be sustained. We have also made a recommendation about the suitability of the registered managers office.

Everyone spoke highly of the registered manager. The improvements she had made throughout the service continued to be recognised by people who used the service, their relatives and visitors. It was apparent that the registered manager and the provider had invested a lot of time and money into addressing the previous concerns and were committed to ensuring Waterloo House was a safe place for people to live.

Established safeguarding procedures continued and all staff were aware of their responsibilities with regards to recognising and reporting any suspicions of harm or abuse. Individual risk assessments were in place to assist the staff to support people in a safe manner. Actions which staff could take to mitigate risks were clearly documented. Accidents and incidents continued to be recorded, monitored and reported to the local authority and CQC as necessary.

Emergency plans were in place and staff demonstrated their understanding of the procedures. Personal emergency evacuation plans were in place for each individual and were regularly updated to ensure the service held an up to date record of the support people would need to evacuate the building in an emergency.

Staff recruitment was robust; the registered manager ensured pre-employment vetting checks including references and police checks were in place before new employees commenced their duties. Staff were monitored for suitability through a probationary period and were closely supervised until they were assessed as competent in the role. There were enough staff employed at the service to meet people’s needs. Staff confirmed they had enough time to complete their duties; people and relatives told us the staff were available whenever they needed them.

Medicines were now managed safely. We observed staff safely administered medicines to people during our visit. Procedures were in place to ensure medicines were ordered, stored, administered and recorded appropriately. There were no unexplained gaps in the recording of administration and the previous issues with the medicine room had been addressed.

Improvements to reduce the risk of cross infection had been made. The standard of the environment had improved and we observed the home to be clean and tidy. Staff followed best practice guidelines in relation to the control of infection in order to minimise cross contamination. Domestic staffing levels had been increased since our last inspection.

Staff continued to be inducted into the service and trained in topics which were relevant to their job. The registered manager sourced external training to enhance their skills and knowledge. The registered manager completed competency checks on the staff to ensure they continued to be fit for their role.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS), and to report on what we find. The registered manager told us she had made applications on behalf of most people to restrict their freedom in line with the Mental Capacity Act 2005. All staff demonstrated an understanding of the MCA and worked within its principals.

People were supported by staff to eat and drink well. Kitchen staff provided a healthy, well balanced diet. There was a choice of meals from a menu and alternatives were available. Special dietary requirements were adhered to including pureed food and a diabetic diet.

People and relatives told us the registered manager and staff were extremely caring. They were impressed with the support provided by all staff at the home, as was the external professionals we spoke with. We observed staff were kind and considerate of people’s capabilities and varying needs. We saw staff treated people with respect and ensured their privacy and dignity were maintained. All staff were helpful, friendly and professional throughout our visit.

Records showed that where appropriate, people had been involved in planning their care. Relatives confirmed that they had been involved in devising care plans and they had shared information about their relations in order to help the staff get to know people better. The care records were detailed and person-centred. They contained assessments of people’s needs, personalised care plans and individual risk assessments. They were regularly reviewed and updated.

An activities co-ordinator provided one-to-one support to people as well as organising communal activities and outings. There was a planned programme of meaningful activities on display and all staff had been involved with parties, theme nights and celebrations to reduce social isolation.

There had been no complaints since our last inspection and during our visit nobody raised any concerns with us. The feedback we received from relatives and external professionals was positive.

The inspection took place on 7 July 2016 and was unannounced. This meant that the provider and staff did not know that we would be visiting. Two announced visits were carried out on 8 and 13 July 2016 to complete the inspection.

We previously carried out a comprehension inspection on 29 April 2015 and 1 May 2015 where we identified a breach relating to the premises and equipment. We found that the premises were not clean or well maintained. Following our inspection, we received information of concern relating to staffing levels. We carried out a responsive inspection in June and September 2015 and identified a further two breaches relating to staffing levels and the governance of the service. We also found further concerns with the premises and equipment. We rated the service as ‘Requires improvement’ and judged the ‘Well led’ domain to be ‘Inadequate.’ After both the comprehensive and responsive inspections, the provider wrote to us to say what action they were taking to meet legal requirements.

We inspected the service again on 7 and 8 and 13 July 2016 to check that action had been taken and carry out a full comprehensive inspection. We found that improvements had been made with regards to staffing. However, we identified continuing shortfalls with the safety and governance of the service.

Since 2012, the provider had been in breach of the regulation relating to the premises on five occasions. We had previously issued two warning notices in September 2012 and September 2014 with regards to the premises. Despite the provider taking action to meet the requirements of the warning notices, improvements regarding the premises were not sustained.

At this inspection, we spent time looking around the service and found concerns with the environment. One fridge in the kitchen was rusty and stained, another fridge was leaking. In addition, staff told us that there should be a guard between the cooker and deep fat fryer for fire safety. The flooring in the kitchen, office and other areas of the home was uneven and damaged which was a trip hazard and the roof leaked during heavy rainfall.

There was a quality assurance system was in place to monitor the service. We concluded however, that this was ineffective since action was not taken in a timely manner to ensure the safety of all those concerned. We also found shortfalls with record keeping relating to the management of the service and people.

We noted that the previous CQC inspection ratings were not displayed at the service in line with legal requirements. The manager told us that a person with a dementia condition kept removing the poster which displayed the ratings. We spoke with the director about this issue. He told us that this would be addressed.

There was 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 and associated Regulations about how the service is run.

There were safeguarding procedures in place. Staff knew what action to take if abuse was suspected. They were fully aware of the whistle blowing procedure.

Safe recruitment procedures were followed. No concerns about care staffing levels were raised by people or relatives. We observed that staff carried out their duties in a calm unhurried manner. Some staff told us that more domestic staff were required to maintain environmental standards. We observed that some areas of the home including the bathrooms were not as clean as they could have been. We made a recommendation that domestic staffing levels are reviewed to ensure that environmental standards are maintained.

The manager provided us with information which showed that staff had completed training in safe working practices and to meet the specific needs of people who lived at the home.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. MCA is a law that protects and supports people who do not have ability to make their own decisions and to ensure decisions are made in their ‘best interests’ it also ensures unlawful restrictions are not placed on people in care homes and hospitals. We made a recommendation at our last comprehensive inspection on 29 April and 1 May 2015 that records evidenced care and treatment is always sought in line with the Mental Capacity Act 2005. We found however, that this had not been actioned.

The manager had submitted DoLS applications to the local authority to authorise in line with legal requirements.

Staff who worked at the home were knowledgeable about people’s needs. We observed positive interactions between people and staff. People were supported with kindness and care. Care plans were in place which gave staff information about how people’s needs were to be met. Staff had started to complete ‘one page profiles’ which gave an overview of people’s needs and helped staff provide care in a more person-centred way.

There was an activities coordinator employed to help meet the social needs of people. People and relatives told us that there was enough going on to occupy people’s attention. There was a complaints procedure in place. Meetings and surveys were carried out.

The overall rating for this service is ‘Requires improvement.’ However, we are placing the service in 'special measures.' We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, it will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to safe care and treatment and good governance. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

We considered all the evidence we had gathered under the regulations we inspected. We used the information to answer the five questions we always ask;

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

This is a summary of what we have found:

Is the service safe?

We found that improvements had been made regarding the condition of the premises and people were now protected against the risks associated with unsafe premises.

Is the service effective?

This question was not reviewed. Our inspection was carried out to check whether the provider had taken action to improve the condition of the premises. This question will be answered at a later date.

Is the service caring?

This question was not reviewed. Our inspection was carried out to check whether the provider had taken action to improve the condition of the premises. This question will be answered at a later date.

Is the service responsive?

This question was not reviewed. Our inspection was carried out to check whether the provider had taken action to improve the condition of the premises. This question will be answered at a later date.

Is the service well led?

We did not inspect all aspects of this question. A manager was in place. She was not yet registered with the Care Quality Commission (CQC) in line with legal requirements at the time of our inspection. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

The manager was due to have an interview on the afternoon of our inspection with a CQC registration inspector who would assess her ability to manage the home, according to the criteria outlined in the CQC Registration Regulations 2009.

Following our inspection, the manager successfully registered with CQC as a registered manager.

We considered all the evidence we had gathered under the regulations we inspected. We used the information to answer the five questions we always ask;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

This is a summary of what we have found:

Is the service safe?

Not all aspects of the service were safe.

People told us that they were happy with the environment and their bedrooms. One person told us, “I’ve got everything I need.” A relative said, “It’s an old building, but everything seems to be in order.” We found however, that maintenance and servicing were not always carried out in a timely manner. Parts of the building such as the windows were in disrepair.

We have issued a warning notice in relation to the condition of the premises and have told the provider to take action.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The manager was aware of the recent Supreme Court judgement regarding what constituted a deprivation of liberty. She was working with the local authority to consider the implications which this ruling had on people who lived there.

Is the service effective?

The service was effective.

Referrals to health and social care professionals were carried out in a timely manner which helped meet people’s health care needs.

Is the service caring?

The service was caring.

People and relatives were positive about the care provided by staff. One person said, “I couldn’t ask for better.” Relatives confirmed this. One stated, “It’s a homely caring place.”

We saw that people were treated with kindness and patience. Each person had a care plan which aimed to meet people’s physical, emotional and spiritual needs. The manager told us of her plans to make these care plans more personalised.

Is the service responsive?

The service was responsive.

People were supported to continue their hobbies and interests. We saw that people were supported to access the local community. Holidays were also arranged for one person who enjoyed visiting further afield.

There was a complaints procedure in place. None of the people or relatives with whom we spoke told us they had any complaints. One relative told us, “I have no complaints, only compliments.”

Is the service well led?

Not all aspects of the service were well led.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Her name appears because she was still a registered manager on our register at the time. A registered manager is a person who has registered with CQC to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

There was a manager in place. She had not yet registered with the Care Quality Commission (CQC) to be a registered manager. We have written to the provider to find out their plans to have a registered manager in place.

We noted that a number of audits were carried out to monitor health and safety. We saw that the manager had highlighted the same environmental concerns such as the condition of the windows, the sluice room and the dining room furniture. We saw that maintenance issues were not always completed in a timely manner.

We were unable to speak to all of the people who used the service because of the nature of their condition. We spoke with staff and observed their practices to determine how care and support was delivered.

We found people’s needs were assessed and care and treatment was planned and delivered in line with their individual care plans. Relatives we spoke to were positive about the care and support people received. One relative told us, “It’s not the Ritz, but overall the care is brilliant. I’m really happy he’s there.”

We found that people were provided with a choice of adequate nutrition and hydration.

The home was clean and we saw there were effective systems in place to reduce the risk and spread of infection. One relative said, “My mum's room is always spotless."

We saw that there were suitable numbers of skilled, trained and experienced staff.

The provider had a written complaints policy and procedure that detailed the process to be followed in the event of a complaint. People and relatives told us that they felt able to raise any concerns or comments about the service and that they had no complaints to make.

We walked around the premises and viewed equipment which had been refurbished or purchased since our last visit.

We found the provider was now protecting people against risks associated with unsafe or unsuitable premises. In addition, we found the provider was also protecting people against risks associated with unsafe or unsuitable equipment and that equipment was now available in suitable quantities to ensure the welfare of people.

On the day of our inspection, 30 people were using the service. We began our inspection at 5.50am and found that two people were dressed and sitting in the lounge at that time. One person told us, "They (the staff) always get me up." Staff told us the person had been sitting on the edge of their bed and had wanted to get up. We saw that the person's care plan documented their preference to get up early.

Approximately 6.15am, one other person was out of bed and dressed but they had done this independently. We asked if they were happy to be awake at that time and they told us, "Yes, I used to work on a farm."

Three staff had been on nightshift and they told us that no-one was woken up or dressed if they didn't want to be. We later spoke with the manager, and other staff, who provided information and examples to demonstrate that people got up and dressed when they wanted to.