Waterloo House

Waterloo House is a residential care home providing personal care and accommodation for up to 19 people with mental health needs. At the time of this inspection there were 17 people living in the service. Accommodation is spread over three floors. Waterloo House is an older style property in Stoke, a suburb of the city of Plymouth in Devon.

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

The inspection was prompted following concerns raised to the Care Quality Commission about staffing, leadership and management not listening to concerns raised. At the time of the inspection, the manager was not registered with the Care Quality Commission (CQC) and had been in post for four months.

The premises were in need of repair, redecoration and refurbishment. People, relatives, staff and health and social care professionals all commented on the poor environment. We identified an immediate high risk for people accessing the garden and the manager acted immediately and installed a temporary ramp, grab rails and undertook risk assessments to minimise the risk for people.

The service had a fire inspection and had been served with an enforcement notice of non-compliance which meant that the service was not meeting fire safety regulations and was not safe. The provider had responded to the fire enforcement notices, and contractors were working at the property to make sure the physical environment complied with fire safety requirements. It is of concern that the provider had not been proactive in addressing the risks to the premises until they were highlighted by other agencies.

Care plans would benefit from expansion to provide staff with more detailed information. For example, information on events that were likely to cause people anxiety and guidance for staff on how to provide support at these times. This could lead to people receiving inconsistent care.

People’s risk in areas such as falls had not always been assessed. This meant that staff did not have a risk assessment that could inform, direct or guide them on how to minimise these risks.

The manager was new to the service. They had received some feedback, guidance and support in carrying out their role from the provider. People, staff and the management team told us that the provider was not visible in the service.

The review of records and care documentation evidenced there was poor oversight of the service, which was affecting aspects of the operation of the service. There were no formal auditing systems in place. We were not assured management were reviewing all incidents and identifying themes or learning to mitigate the risk of them happening again.

The manager was keen to learn from the inspection process and act on issues identified. Feedback from people, a relative, staff and health and social care professionals were positive about the current management team. They felt changes to the service were now occurring. For example, changes to the premises, improved care records and communication and felt that, “morale has lifted”. All stated that they felt able to approach the manager with any concerns about the service, or care and that they would be listened to.

People told us they felt safe and cared for. People were encouraged to report any concerns they may have about their welfare to the manager or senior staff.

People were encouraged to be involved in the interests and activities that they enjoyed and to maintain relationships which were important to them.

People and relatives were complimentary about the staff support and their skills. Comments from people included, “The staff are good people”. A relative commented “All the staff are absolutely brilliant, the service they provide is wonderful, it's friendly, very helpful and pleasant, the way they interact with my mum is great as they have got to know her and they know how to manage her good days and her bad days now very well.”

Staff told us they felt very supported by the new management team and had access to a range of training to support them in their roles.

Staff knew how to report and escalate any safeguarding concerns. People received their medicines safely.

People and relatives told us they felt that there were always sufficient staff on duty. The services recruitment practices were robust.

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

People’s health conditions were well managed, and staff engaged with external healthcare professionals. Staff were proactive in making timely referrals to health professionals when they had concerns around people’s health and well-being.

Concerns, raised by people, had been investigated thoroughly and a response provided to the complainant. From this the manager had reflected what learning could be taken from the concern raised and shared the findings with staff.

There was good communication within the staff team and staff shared information appropriately.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Last rating and update

The last rating for this service was good (published 16 December 2020).

Why we inspected

We received concerns in relation to staffing, leadership and management not listening to concerns raised. As a result, we undertook a focused inspection to review the key questions of safe, effective, responsive and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

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 see what action we have asked the provider to take at the end of this full report.

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

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.

Enforcement

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 found three breaches in relation to the premises, care records and the oversight and leadership of the service at this inspection.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Waterloo House is a residential care home providing personal care and accommodation for up to 14 people with mental health needs. Accommodation is spread over two floors. Waterloo House is an older style property in Stoke, a suburb of the city of Plymouth in Devon.

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

People we spoke with were all happy with the service. For example comments received included: “It is very good,” “It is excellent,” and “I love it here.”

People were positive about the food, said they had enough to eat and were offered a choice. People could make a hot or cold drink when they wanted. There was a smoking room, in the back garden, which people could use if they wished.

People said they could go out if they wished. Staff provided some activities such as quizzes, bingo, and film afternoons. One of the staff was recently appointed as an activities co-ordinator, and took people out on trips in the minibus. The activities co-ordinator was planning to expand the activities available.

The service had suitable safeguarding systems in place, and staff knew how to recognise and what to do if they suspected abuse was occurring.

Risk assessment procedures were satisfactory so any risks to people were minimised. All other care documentation was informative, up to date, and regularly reviewed.

Staff were recruited appropriately. Overall, satisfactory recruitment procedures were followed in line with interim guidance issued by CQC during the Covid 19 Pandemic.

The building was clean, and there were appropriate procedures to ensure any infection control risks were minimised. 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 coronavirus and other infection outbreaks effectively.

The team worked well together and had the shared goal of providing a good service to people who lived at the service.

The service was managed effectively. There were appropriate audit and quality assurance systems in place. People, relatives and staff had confidence in the management 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

The last rating for this service was Good (published 1 January 2019).

Why we inspected

We undertook this focused inspection to check standards had been maintained following a series of management changes at the service. We looked at infection prevention and control measures under the Safe key question. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

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.

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

Waterloo House is a 'care home' that supports people living with mental health needs. 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.

CQC only inspects the service being received by people provided with 'personal care'; help with tasks related to personal hygiene and eating. Where they do we also take into account any wider social care provided. The service provides care and accommodation for up to 20 people. On the day of the inspection 14 people were staying at the service.

The service is owned and operated by Vivacare Limited, who also own another care home in East Cornwall called Tremanse House.

There was a manager in post, who had just had their interview with the Commission to become the registered manager of the service. 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.

We found that action had been taken to improve the systems for monitoring the safety and quality of the service.

New monitoring checks had been devised and implemented. The provider had employed a new compliance lead who had responsibility for visiting the service on a weekly or monthly basis to meet and support the manager, carry out independent audits and feedback to the provider. In addition, the provider visited the service on a three-monthly basis to meet with staff and speak with people living at the service. This helped to monitor the overall culture and ensure that regulations were being met.

Further information is in the detailed findings below.

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.

The care home provides accommodation and personal care for up to 20 people who have mental health needs. On the day of the inspection 14 people were living at the service. The provider also operates another mental health care home in Cornwall.

We carried out a previous comprehensive inspection on 21 and 22 June 2017. The service was rated requires improvement, but remained 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 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.

We told the provider to make improvements to ensure people’s medicines were managed safely, and that infection control practices were implemented to help reduce the unnecessary spread of infection. We also told the provider to ensure staff received training so that they could meet people’s needs effectively, and that people’s human rights were protected. In addition, we asked the provider to improve the leadership of the service, update policies and procedures and implement an effective monitoring process to help identify when improvements were required. In line with our enforcement policy we took action to impose a positive condition on the provider’s registration, which meant on a monthly basis they were required to send us an action plan relating to infection control procedures, care plans and risk assessments.

During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures, but further improvements regarding the provider’s monitoring systems are still required.

Since our last inspection, the previous manager had left, and a new manager had been employed and had had submitted their application to the Commission to become the registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered person's'. 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’s medicines were now managed safely. People were now protected from good infection control practices. Staff had received training in infection control, and put their knowledge into practice.

People told us they felt safe. People were protected from abuse because staff knew what action to take if they suspected someone was being abuse, mistreated or neglected.

Overall, people lived in an environment which was safe. The shed in the garden now had a padlock, and items which could pose a risk within the service were locked away. However, water temperatures in three bathrooms were found to be very hot. The manager explained a new maintenance person had been employed, and one of their roles would be to ensure water temperatures are at the correct temperatures. A new monitoring system was also being put into place to help ensure the ongoing safety of the environment.

People were encouraged to take risks. Risk assessments were in place to help support risk taking, and help reduce risks from occurring. People who had behaviour that may challenge staff or others had risk assessments in place which gave good guidance and direction to staff about how to support the person, whilst taking account of everyone’s safety.

People had their needs met by suitable numbers of staff. Staff responded promptly to people when they needed support, and had time to sit and spend with them socially. Staff, were recruited safely, and checks carried out with the disclosure and barring service (DBS) ensured they were suitable to work with vulnerable adults.

People’s human rights were now protected. Best interests meetings had been carried out in line with the Mental Capacity Act 2005 (MCA) when restrictive practices were in place, records showed that staff, were supporting people to work towards independence and recovery. People’s consent to care was documented, and staff respected people’s wishes when they chose not to do something, such as take their prescribed medicines.

People were now supported by staff who had received training to meet their needs effectively. Staff meetings, one to one supervision of staffs practice and appraisals of performance, were being undertaken with staff telling us they felt “supported”.

People’s health and social care needs were holistically assessed. The provider worked closely with external health and social care professionals, to help ensure a coordinate approach to people’s care.

People’s communication needs were known by staff. Staff had received training in how to support people with different communication needs. The provider had taken account of the Accessible Information Standard (AIS). The AIS is a requirement to help make sure people with a disability or sensory loss are given information they can understand, and the communication support they need.

People enjoyed the meals, and people’s individual preferences were catered for. People had independent access to cold and hot drinks, and had care plans in place to support their nutrition.

People lived in an environment which was adapted to their needs. A decoration programme for the service was in place, and people were being part of decisions about colour schemes.

People were supported by kind staff. Staff all spoke of their love and passion for their job, and for the people living at the service, describing it like “a family”.

People were given emotional support when distressed and were involved in making decisions about their own care. People had access to independent advocacy services, and were supported to access these when required.

Overall, people’s individual equality and diversity preferences were known and respected. Some people had care plans in place detailing their religious and cultural needs, with one person telling us “If I want to go to church I ask the staff and they make sure I can go”.

People’s privacy and dignity was promoted and their independence was encouraged. People’s bedrooms were personalised, and people’s family and friends were welcomed warmly by staff. Special occasions such as birthdays were celebrated.

People received personalised care and support. People received a pre-assessment of their care prior to moving into the service. People’s pre-assessment was then used to form the basis of their individualised care plan, providing staff with information about how to meet people’s needs in the way they wanted and needed their needs to be met. Care plans were based on people’s health and social care needs, and supported their ongoing mental health recovery.

People’s care plans were reviewed to help ensure they were reflective of people’s current care needs. People, if they wanted to be, were part of the review and care plans detailed when people had been involvement in making amendments.

People had the opportunity to engage in social activities, however whilst no one complained about the availability of social activities, social activities were not structured each day, which meant people may not always feel motivated or have something to look forward to. The manager positively listened to our feedback, and told us they would address this by speaking with people to obtain their views.

People’s end of life wishes had been discussed and had been detailed in people’s care plans. When people had not wanted to talk about their end of life wishes, this had been respected and recorded.

The new manager and provider had devised some new systems and processes to help monitor the ongoing safety and quality of the service, and further audits were being devised and implemented.

The provider visited the service on a monthly basis, to meet people, staff and to discuss the day to day management of the service with the manager. Whilst this provided some assurances about the ongoing quality and safety of the service, the provider was not specifically checking the work of the manager. Therefore, the provider themselves had recognised that these visits needed to be more robust, so told us they would be appointing a person to carry out a monthly visit of the service.

People lived in an environment which was positive and inclusive. During our inspection, the manager and staff team displayed through their interactions the provider’s mission statement of “A client is the most important person in our care home. They are not an interruption to our work, they are the purpose to it. They are not an outside in our home, they are part of it, as it is their home. We are not doing them a favour by serving them, they are doing us a favour by allowing us the opportunity to do so”.

The new manager did not have experience of mental health but had access to mental health advice from the manager of the providers other care home. To strengthen the mental health expertise within the service, the provider told us they would be recruiting a deputy manager with mental health experience. The local authority service improvement team, told us they felt mental health leadership was lacking.

People lived in a service whereby the provider learned from their mistakes in order to help improve the service. People, staff and the public were invo

Waterloo House is a care home which provides accommodation and personal care for up to 20 people who have mental health needs. On the day of the inspection 17 people were living in the service (Two people were in hospital).

At the last inspection on the 12 and 25 October and 1 November 2016 we found significant concerns relating to managing people’s care and risk, care planning, infection control and prevention, safeguarding people from harm, staff training and knowledge, the environment and leadership. We rated the service as inadequate overall. In line with our enforcement policy we made the decision to place conditions on the provider’s registration. We told the provider they must send us monthly reports to tell us about their progress to address the concerns raised. This condition will remain in place until we are satisfied sufficient improvements have been made. We found most breaches had been met but had concerns about medicine management and the governance systems within the home.

The service has also been in Special Measures. Services are placed in special measures when they have been rated as inadequate overall. 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.

The overall rating for this service is ‘Requires improvement’. However, the service will remain 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.

At the time of the October 2016 inspection the service did not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered person’s’. 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. Following the October 2016 and at the time of this inspection, a consultancy service with mental health experience was working with the provider to support improvements at Waterloo House. The provider was actively trying to recruit to a registered manager.

Following the last inspection in October 2016 we requested that the provider send us monthly reports on their progress to address areas of concern we had found. We received reports as requested and also met with Plymouth City Council to discuss the action taken to improve the quality and safety of services provided to people at Waterloo House. The quality monitoring team for Plymouth City Council told us the consultancy team had worked closely with them and had been open and responsive when discussing the concerns found and action needed.

People and other agencies said they had seen improvements in the service during the last six months. The provider and consultancy team had spent time with staff discussing the concerns found at the last inspection and had considered what factors may have contributed to these failings. They said they had involved all the staff in these discussions and listened carefully to their views and feedback. The consultancy team said they recognised the changes were work in progress, but felt positive progress had been made so far. Staff said improvements had been made and they felt more valued and involved in decisions about the service. Staff said they were very happy working in the home. All staff were working together as a team and keen for the service to improve.

At this inspection we found improvements had been made but further work was needed in relation to infection control, medicine management, meeting staff training needs, understanding of the Mental Capacity Act (2005) and the provider’s governance systems, including updating policies to guide and direct staff. The consultancy team had prioritised areas they had considered to be of highest risk, and had addressed these within agreed timescales. They said they were aware further improvements were needed and were working closely with staff to embed some of the changes and working practice.

Medicine management processes were not always safe. We found some discrepancies with people’s stock balances which could not be explained. People did not have care plans in place to guide medicine administration to ensure there was consistency across staff administering and guidance in place for when “as required” medicines might be needed. There was no a clear policy in place regarding medicine administration and there was no an audit of the medicine administration processes. The consultancy team were proactive in addressing these issues immediately undertaking an internal audit, sourcing advice and arranging in house training on best practice in this area. Further external training was being arranged for staff leading on medicines within the service.

People were protected by safer infection control practices. The home was found to be clean and well-maintained. Action had been taken to address concerns raised at the last inspection. We found the infection control policy and audit required updating to reflect best practice and staff required refresher training in this area. We have issued a recommendation in this area.

People were assured a better quality of service due to the new quality assurance programme. Reviews had been undertaken of the home’s quality auditing systems and improvements found in the service demonstrated these were now more effective. However, there were gaps in the service’s quality auditing processes at the time of the inspection. This was being addressed proactively by the consultancy service. The provider’s governance framework was also not clearly evidenced to demonstrate how they ensured the service was providing high quality.

Staff told us how they always asked people for their consent as they provided care, and we observed this in practice. Not all staff had received training on the Mental Capacity Act (MCA) 2005 which would support their understanding of the MCA. The MCA provides the legal framework to access people’s capacity to make certain decisions, at a certain time. When people had been assessed as not having the capacity to make a decision, a best interest’s decision was usually made, involving people who knew the person well and other professionals when relevant. We found recording of best interests decisions needed to be clearer for some decisions, for example if there were set house rules which might be perceived as restrictive. Some staff found it difficult to explain the Mental Capacity Act and how this law protects people’s human rights. They were being supported to understand this through everyday discussions with the consultancy team and in house training whilst formal training dates were arranged. We have issued a recommendation in this area.

People who did not have capacity and who were being deprived of their liberty had the necessary paperwork submitted to the local authority supervisory body. People who had conditions placed upon them due to their mental health needs were known, staff knew what these were and ensured they were met.

People were supported by staff keen to develop their skills to meet their needs. Staff had received some training for example in challenging behaviour, safeguarding and first aid. Staff had also started distance learning training with an external provider. Training needs identified at the last inspection were being planned and the service was awaiting dates for Mental Capacity Act training. Staff had received a great deal of informal training and support from the consultancy service. Training in specific areas of mental health were planned for July 2017. New staff undertook a thorough induction before they started working in the home. Staff said they felt supported by their colleagues and were able to raise concerns and discuss issues about their practice. Supervision (one to ones) for staff had started to provide formal support to staff and support them through the changes being made.

Improvements had been made in the risk assessment process, and we saw all risk assessments had been reviewed and updated. Further improvements to risk assessments were planned with the introduction of a skin care and nutritional assessment tool.

People’s care plans had been reviewed and care plans we looked at included clear information about people’s needs and how they would be met.

People said they felt safe living in the home and would talk to staff about any worries they had. Most staff had updated safeguarding training and said they felt confident and competent to raise concerns if they felt people were at risk.

People said they felt there were enough staff to keep them safe. Staffing levels had been reviewed, and additional staff had been recruited where the need had been identified.

People’s health and dietary needs were met. People had access to a range of healthcare professionals and the feedback from other agencies was positive. We were told the staff made relevant referrals and followed guidance and advice. Care records provided staff with good detail about people’s healthcare needs and staff were familiar with this information. People said the food was of a good standard and they were offered choices when requested.

There was great improvement in activities and people’s hobbies and interests were being considered. People were enjoying swimming and trips out to parks and garden centres. People told us they were really enjoying being out.

The atmosphere in the home throughout the two days was warm and friendly. We saw lots of caring and compassionate interactions between people and the staff supporting them. Staff told us they loved w

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.

This inspection took place on 12 and 25 October and 1 November 2016 and was unannounced. Day one of the inspection was undertaken by one adult social care inspector. Days two and three of the inspection were undertaken by one adult social care inspector and one specialist advisor, who had a background in nursing. The inspection was undertaken following the Care Quality Commission receiving information of concern from the local safeguarding authority and externally employed professionals visiting the service.

Waterloo House is a care home which provides accommodation and personal care for up to 20 people who have mental health needs. At the time of the inspection there were 19 people living at the service.

At the time of the inspection there was no registered manager in post. 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. A new manager had been appointed who was due to commence their role in December 2016.

Following the inspection, CQC made safeguarding alerts in respect of both the whole service, and in relation to four individual people who lived at Waterloo House.

People who used the service were not always protected from the risks of abuse. There were some instances, where people who were at risk of harm, were not reported to safeguarding authorities, or satisfactory plans were not put in place to minimise the risk of harm to others. The details kept by the service of who to contact to discuss safeguarding concerns were seen to be out of date.

People were not kept safe within the environment because infection control practices were not sufficient. There was a lack of Personal Protective Equipment (PPE) within the home, to prevent the cross infection of transmittable diseases. Where people had illnesses which may have posed a risk of cross infection to others, their care plans were out of date and lacked guidance for staff on managing the risk. We observed unsafe practices around infection control in relation to items in bathrooms, such as bath towels. Routines intended keep the home clean and protect people from the risk of cross infection were not always satisfactory. For example the communal drinks station was seen to be dirty with used cups put back in the clean area by people throughout the inspection.

People were not always safe within the environment. We found a number of environmental hazards such as an extremely hot radiator in one of the bathrooms without a protector and obvious ligatures such as long call bell cords and ligature points such as metal hooks in shared bathrooms. We found the maintenance room containing dangerous items such as screwdrivers, machinery and knives to be unlocked and unsupervised. We found that people had PEEPS (personal emergency evacuation plans) in place however they had not been recently reviewed. In addition, they were stored in the back of people’s individual care records and may not have been accessible in a timely manner in the event of an emergency.

Accident and incident forms had been completed in respect or significant events such as when police involvement had been required or when a person had taken too much medicine. These forms lacked important detail such as the date or the outcome of the incident. This would be important in terms of identifying themes and in reducing the likelihood of a reoccurrence. Where incidents had occurred, risk assessments and care plans were not updated in response.

People’s liberty and freedom of movement were not always protected. We found no evidence that people’s capacity to make decisions had been assessed in line with the Mental Capacity Act (MCA), despite some people being subject to authorisations under the Deprivation of Liberty Safeguards (DoLS). We saw no evidence that best interest processes had been followed to ensure people’s care was provided in the least restrictive manner available. We found out of date consent forms which referred to outdated CQC regulations. Where people were subject to other orders, such as the sections of the Mental Health Act (MHA), staff were not always aware of the conditions or restrictions associated with the orders. There was no guidance in people’s care records to inform staff of what this meant for the people they cared for.

There was a lack of activity on offer for people who lived in the home. This meant many people

had little to do apart from watch television. We were told that there was a mini-bus and people went out on trips on an ad-hoc basis, but there were no personalised plans around this in people’s records and no schedule to inform people of planned events.

Care plans did not contain accurate and up to date information, and had not been regularly reviewed. Care plans did not provide suitable guidance to inform staff where people had complex needs which may have put them and others at risk. There were two sets of care records which ran concurrently meaning that some information was duplicated, disorganised and confusing. Some records contained contradictory information. People’s confidential information was not always securely stored.

People had access to healthcare professionals but where they had provided advice, this had not always been followed up by staff. We found little evidence in people’s records to inform us of when people had been reviewed by their GP or had important checks, for example relating to their diabetes or catheter care. The approach from staff to diabetes care and skin management were inconsistent.

There was no registered manager in post. The previous registered manager had left and a new manager had been appointed to commence their role in December 2016. Managerial arrangements for the intervening period were not sufficient to undertake the corrective action that was required to ensure the safety of those living at Waterloo House.

Suitable quality assurance systems were not in place to check the service was operating effectively and to drive improvement where it was required. There were no staff or residents’ meetings which meant staff and people may not have had the opportunity to offer suggestions on the running of the service.

The service had not always informed the Care Quality Commission of important events and incidents in line with their legal obligations which meant there was a risk of a lack of oversight and potential safeguarding of people using the service.

Some aspects of people’s medicines management were not safe. Although people were generally given their medicines as prescribed and on time, where people managed their own medicines the oversight by staff was not always sufficient. Some people were prescribed medicines which required strict controls. Staff were unable to tell us why one person was receiving this medicine. The keys to the drugs trolley and cupboard were not always securely stored. The medicines fridge was situated above a radiator on a window ledge which may have caused problems in maintaining its temperature at the required level although the fridge was in range when we visited.

Staff told us they pressurised and drained, particularly due to some new people who had recently come to live at the service. During our inspection, there appeared to be enough staff on duty. Staff were able to respond to people in a timely manner and appeared unhurried in their interactions. Staff had not received specialised or role specific training in mental health or substance misuse, despite providing support for people who had complex needs and may require a skilled approach to manage their needs effectively.

People told us staff was caring and most staff we spoke with had a compassionate and caring attitude towards the people they supported. We observed some staff interacting in a positive way and using appropriate humour with people using the service. However, we witnessed some incidents which were not professional and respectful.

Staff told us they had undergone an induction and that they received supervision and an appraisal. Staff had received mandatory training and some role specific training in areas such as managin

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 found. The summary is based on our observations during the inspection, speaking with ten people using the service and three staff supporting them. We looked in depth at three care plans and people's daily records and spoke to a mental health professional who had recently visited the home.

Is the service safe?

People told us "It's safe as houses here"; "Yes, I feel safe"; "I've had nothing go missing here, not even a sock!" and "It's a nice place and I feel safe."

People were treated with dignity and respect. We spent time talking to people at the home and observed the care in the lounge for three hours. We noted that all interactions between staff and people were respectful and people's dignity was maintained. We saw in people's care files that prompt referrals for advice and support were made for people when their health deteriorated and the home acted on the advice given. People told us without exception that they felt safe at the home and that there were sufficient staff on duty to meet their needs. The staff we spoke to had a good understanding of safeguarding and understood their responsibilities to protect the people they supported.

CQC monitors the Deprivation of Liberty Safeguards (DoLs) which applies to care homes. The manager told us that they had not had to submit any formal applications but had sought advice for some people regarding their care. There were procedures in place to gain people's views and people felt that any concerns they raised were acknowledged and acted upon.

The Registered Manager set the staff rotas, they took into account people's care needs and social activities when making decisions about the numbers, qualifications, skills and experience required. This helped to ensure people's needs were always met. There were systems in place such as one to one meetings and staff training which helped to maintain safe practice.

Is the service effective?

People told us how much they liked living at the home and that they felt well looked after. A mental health professional told us that some people who had gone to live at Waterloo House had continued with their recovery and were doing very well. The staff we spoke to were knowledgeable about the people they cared for, were well trained and supported in their roles. People's care plans were individualised and considered all aspects of their health and social care. The people we spoke with told us they felt involved with all aspects of their care and that their care plans reflected their needs. We found people's care was regularly reviewed by the appropriate health and social care professionals involved. There was good communication evident through written and verbal handovers and regular staff and resident meetings.

Is the service caring?

People told us "I love all the carers"; "They spend time with us"; "I feel very safe and looked after"; "I'm well looked after"; "It's all good here".

All of the people we spoke with told us they felt happy and well cared for and that the staff were kind and responsive to their needs. Staff told us they also felt cared for and nurtured by the management team. We observed staff caring for people in a kind, unhurried way explaining to people what they were doing and the reason behind the intervention.

People at Waterloo House completed regular questionnaires about their experience of living at the home and we saw the responses were positive.

People's preferences, interests and diverse needs were recorded in their care plans and known by the staff working alongside them. This meant care was provided in accordance with people's needs and wishes.

Is the service responsive?

People completed a range of activities in and outside the service regularly. The home supported people to attend the activities they enjoyed to maintain their social interests.

People knew how to complain and who to speak to if they were unhappy. No one we spoke with had any complaints. People told us that they were confident staff would listen and act upon any concerns they might have.

The mental health professional we spoke to told us that they had been impressed by the assessment process and that the home had been flexible and responsive. The admission process involved an assessment of people's needs to ensure the home could safely care for people, visits to the home and thorough care plans developed with the individual and / or family. The staff we spoke with gave examples of how they had noticed when people's health needs had changed and they had promptly sought advice and support. Staff we spoke with who had been unfamiliar with some health conditions, had done research into specific conditions to gain a better understanding. This meant they were better equipped to meet people's needs.

Is the service well-led?

The service worked well with a variety of health and social care agencies to ensure people's needs were met. Staff told us that they understood their roles and responsibilities, felt confident to seek advice from senior colleagues and felt supported by the management team. There were regular staff meetings and staff regularly met with their line manager.

During our visit to Waterloo house we met with eight people, spoke with four staff on duty and reviewed five care records and five staff files. We found people were involved in decisions about their care and treatment and staff understood the principles of the Mental Capacity Act (2005) which ensured people's human rights were respected.

Care and treatment was provided in accordance with people's needs. A holistic approach was evident in the care records which considered people's physical, mental health and social needs. Evidence of health and social care professionals involvement was apparent. Risks were assessed and updated if people's needs changed. People were able to participate in community activities as they wished.

We saw that the home was clean and well maintained which reduced the risk of infection.

Staff were well trained and supported by the registered manager and deputy manager. Regular supervision, appraisals, training and meetings were in place for staff working at Waterloo House.

There was a system in place to manage complaints and the people living at Waterloo House and the staff were confident complaints would be taken seriously and investigated.

We saw people living in the home being involved in many decisions about how the home was run, including being involved in upgrades to all living areas.

We saw people's privacy and dignity were respected and staff were helpful when assisting people. Comments from people who lived in the care home included, "They (the staff) are very kind' and 'Very kind people'.

Staff were clear about the actions they would take should they have any concerns about people's safety.

We saw and heard staff speak to people in a way that demonstrated a good understanding of people's choices and preferences. We looked in detail at the care three people received. We spoke to staff about the care given, looked at records related to them, met with them, and observed staff working with them. We saw that the staff had a good understanding of people's individual needs and that they were kind and respectful. They took time to work at people's own pace.

We saw that people's care records described their needs and how those needs were met. We saw that people consent to all areas of their lives including consent to the home administering their medication.