Waverley Lodge

Updated 5 October 2023

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 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

The inspection was carried out by 2 inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Waverley Lodge 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 Lodge 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 service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.

An interim manager was in post during our visits to the home. A new manager had been recruited and was in post by the end of our inspection.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 16 May 2023 and ended on 19 June 2023. We visited the care home on the 16 and 18 May 2023.

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 professionals who work with the service. We also contacted Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used all this information to plan our inspection.

The provider did not complete a 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. Please see the well-led section for further information.

During the inspection

We spoke with 4 people and 12 relatives. We also spoke with staff including the operations director, divisional director, regional manager, interim manager, deputy manager, care staff, activities coordinator, administrator, laundry and domestic staff and the maintenance man. We reviewed records relating to people’s care and medicines and records relating to staff and the management of the service.

Updated 5 October 2023

About the service

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.