The inspection took place on 20 and 21 June 2018 and was unannounced. This meant the provider and staff did not know we would be coming. 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Risk assessments and care plans were often out of date or inaccurate, putting residents at risk.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.