Waverley Lodge

Updated 9 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.

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 one inspector and 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.

At the time of our inspection a manager was in post who had applied to become a registered manager.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 17 August 2022 and ended on 30 September 2022. We visited the care home on the 17 and 23 August 2022.

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 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 with three people, 12 relatives, 16 staff including the divisional director, regional manager, manager, deputy manager, senior care worker, care workers, domestic staff, cook and kitchen assistant. We reviewed records relating to people’s care and medicines and records relating to staff and the management of the service.

Updated 9 January 2024

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 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.