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Archived: Waterbeach Requires improvement

The provider of this service changed - see old profile

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Inspection Summary

Overall summary & rating

Requires improvement

Updated 16 June 2016

Waterbeach is registered to provide accommodation and non-nursing care for up to 4 people. There were 4 people with a learning disability living in the home at the time of the inspection. The accommodation is a bungalow and all bedrooms are for single use.

This unannounced inspection took place on 19 and 20 April 2016.

At the last comprehensive inspection on 12 and 13 October 2015 this provider was placed into special measures by CQC. A breach of nine legal requirements was found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet the legal requirements in relation to:

• providing care that was appropriate, safe and met people’s needs,

• treating people with dignity and respect,

• ensuring that the requirements of the Mental Capacity Act 2005 were met

• safe management of people’s medicines,

• maintaining the premises,

• assessment and monitoring of the service,

• sufficient numbers of competent staff to meet peoples assessed needs.

During this inspection we found that there was sufficient improvement to take the provider out of special measures. We found that the provider had followed their plan which they had told us would be completed by 31 March 2016 to show how the legal requirements were to be met. Some improvements were still needed.

There was a registered manager at the time of the inspection. However they were no longer working in the home. A new manager had recently been appointed. 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.

Improvements had been made to ensure that only competent staff administered medicines. Weekly and monthly medicines audits were being carried out and had highlighted any issues and appropriate action had been taken where necessary. Improvements were still needed to ensure that there was a clear record of the medicines in stock.

The Care Quality Commission (CQC) is required by law to monitor the Mental Capacity Act (MCA) 2005, Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The provider was acting in accordance with the requirements of the MCA including the DoLS. The provider was able to demonstrate how they supported people to make decisions about their care. Where people were unable to do so, there were records showing that decisions were being taken in their best interests. DoLS applications had been submitted to the appropriate authority. This meant that people did not have restrictions placed on them without the correct procedures being followed.

People’s care plans had been updated to include information that staff required to meet people’s needs. We found that some information was still not accurate. However we found that staff could tell us how they met people’s needs. All of the care plans were being transferred to a new format which should make them easier to use and contain up to date accurate information..

Risks to people had been assessed. The majority of the risk assessments identified how staff should reduce the possibility of risks to people. Some risk assessments needed further information adding to them to ensure that staff had all the information they required to ensure that risks to people were identified and minimised where possible. Accidents were being were being reviewed to prevent a reoccurrence.

There was a robust recruitment procedure to ensure that only the right people were employed. There was a sufficient number of suitably skilled and competent staff working each day. Staff had completed training courses and competency assessments since the previous inspection to ensure that they could meet people’s needs. Staff were aware of the procedures to follow to reduce the risks of people being harmed b

Inspection areas


Requires improvement

Updated 16 June 2016

The service was not always safe.

Improvements had been made to ensure only competent staff administered medicines. However further improvement was needed regarding the recording of medication in stock. This meant that we could not ensure the correct amount of medicine had been given.

The majority of the risk assessments included the information that staff required to reduce risks to people.

Staff were aware of the procedures to follow if they suspected someone may have been harmed.



Updated 16 June 2016

The service was effective.

Staff demonstrated their understanding of the Mental Capacity Act,

2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Staff used innovative ways to ensure people were involved in decision making. Capacity assessments, best interest decisions and DoLS applications were completed as appropriate.

People were supported to access the appropriate health care professionals as needed.

Staff had received training to ensure that they were competent to meet people�s assessed needs.



Updated 16 June 2016

The service was caring.

The care provided was based on people�s individual needs and choices.

Members of staff were kind and caring.

People�s rights to privacy and dignity were valued.


Requires improvement

Updated 16 June 2016

The service wasn�t always responsive.

Care plans had improved and included key information that staff required to meet people�s needs. Further improvements were needed to ensure that the care plans accurately reflected the care and support that people required.

People�s personal care needs hadn�t always been met in a way that they preferred.

A complaints procedure was in place and had been discussed with people.



Updated 16 June 2016

The service was well-led.

Staff were able to discuss any concerns they had with the manager. Staff felt confident in raising their concerns regarding any poor practice they had seen.

The service had an open culture and welcomed ideas for improvement.

An effective quality assurance process was in place.