Watermoor House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Good.

This meant people were safe and protected from avoidable harm.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a proactive culture of safety based on openness. They did not always follow-up concerns about safety, however they did investigate and report safety events. Lessons were learnt to continually identify and embed good practice.

Staff did not always demonstrate a clear understanding of how to recognise, report and escalate safety concerns. This was especially evident when someone required daily monitoring such as fluids.

However, the registered manager routinely reviewed accidents and incidents which happened within the service, to ensure they were properly identified, managed, and followed up. Information about lessons learnt were shared effectively throughout the service. The registered manager held daily staff meetings with the deputy manager and senior care staff in the service to discuss any issues affecting people’s day to day care and to highlight potential learning needs related to delivering safe support. Documents we reviewed for these meetings, showed evidence of shared lessons learnt from previous accidents or incidents. Actions were shared and tracked during the meetings with leaders regarding accidents and incidents

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff appropriately identified risks to people, and risk assessments provided staff with guidance on how to manage and mitigate those risks. People were supported by staff who were familiar with their needs. Staff were able to tell us how they identified and managed risks to people, to help keep people safe from harm and potential abuse.

People told us they felt safe when receiving care. One person told us about a specific piece of equipment they had which reduced their risk of skin breakdown. Another person told us about how the staff moved their furniture in their room around after they had a fall to help prevent them from falling again.

Comments from people included, “The staff are good at reminding me to use my walking frame”, “Staff do check all my equipment is working regularly.” and “Staff are trained in [specific medical condition] well enough.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff appropriately identified risks to people, and risk assessments provided staff with guidance on how to manage and mitigate those risks. People were supported by staff who were familiar with their needs. Staff were able to tell us how they identified and managed risks to people, to help keep people safe from harm and potential abuse.

People told us they felt safe when receiving care. One person told us about a specific piece of equipment they had which reduced their risk of skin breakdown. Another person told us about how the staff moved their furniture in their room around after they had a fall to help prevent them from falling again.

Comments from people included, “The staff are good at reminding me to use my walking frame”, “Staff do check all my equipment is working regularly.” and “Staff are trained in [specific medical condition] well enough.”

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The provider maintained safe staffing levels, and staff responded promptly to people’s needs, including answering call bells without delay. Records confirmed a stable team with routine supervision, including additional oversight for staff on sponsorship arrangements. Meeting minutes confirmed the registered manager held monthly staff meetings and attended daily handovers, which reinforced professional standards and decision‑making responsibilities. The registered manager described the team as hard‑working and engaged.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff managed and controlled risks of infection. The service had systems to maintain and monitor cleanliness including cleaning schedules and an Infection, Prevention and Control (IPC) audit. Staff completed cleaning schedules. The IPC audit was sufficiently detailed which led to effectively identifying and addressing the concerns we saw during our previous inspection. At the last inspection we found there were no cleaning staff employed on Sundays, this led us to question the veracity of the service’s ability to safely manage infections and potential outbreaks. At this assessment we found the provider had recruited a new housekeeper to cover Sundays. Staff now had access to the provider’s IPC policy. Staff disposed of gloves and other waste in line with IPC policies. The locks leading to the internal courtyard had been changed and a new risk assessment was completed with improved control measures in place. People had positive views on infection control and told us the service supports them to wash and shower regularly. People told us the service was clean and they liked their rooms.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

At the previous inspection we found significant concerns around medicine management and issued a warning notice to the provider. At this inspection, we checked if the provider had made improvements in the areas we had found were significantly unsafe. We found the provider had made improvements and were no longer in breach of the regulations. We found the provider had implemented PRN protocols, implemented a medication error logbook and audit and they conducted an audit on liquid controlled drugs to ensure opening dates are recorded. However, we found some areas where the provider needed to continue to make improvements to ensure consistent and safe medicines management. We did not find anyone had come to harm because of the areas identified which needed further improvement.

The service needed to make some improvements to how they ensured medicines needing to be returned to the pharmacy were safely stored.

Some medicine trained staff had not had recent training on how to apply prescription creams, and more work was needed to ensure training and competency assessments were carried out.

Staff were completing Controlled Drug (CD) stock balances. Most controlled drugs had the correct date‑of‑opening and expiry information recorded. However, 2 medicines were found to have incorrect expiry dates on their labels when opened, although both were still within date. One insulin pen in use did not have an opening date recorded by the district nurses. This meant the provider could not be assured insulin was being used safely, as the absence of an opening date prevented effective monitoring of expiry. This was raised on inspection, and the registered manager planned to inform the district nursing team. Crossing out and overwriting were noted in the CD register, indicating entries were not completed in line with required record-keeping standards.

Temperature records for the fridge showed some occasions when the minimum temperature dropped below 2°C, and the actual temperature reached 0°C on 2 occasions. No evidence was found that rechecks were completed when temperatures fell outside the 2-8°C range. This meant the medicines might not have been kept at the correct temperature, which could reduce how well they worked.

The service did not have fire risk assessments for the use and storage of emollients. This meant the fire risks associated with emollient use may not have been properly identified or managed for people.

Some medicines were prescribed PRN which indicates that medication should be taken only, when necessary (e.g., for pain or symptoms), rather than on a strict schedule.PRN protocols were available for people; however, issues were identified. Some protocols with variable doses (e.g. 1–2 tablets) did not provide guidance on how to decide which dose to administer. Some protocols required additional person-centred detail, such as the severity of breathlessness or the person's typical bowel habits related to constipation. PRN follow-up (effectiveness monitoring) was not recorded. For example, where paracetamol was given, but the required follow-up was not documented.

Homely remedies were being administered; however, staff were using medicines from the homely remedy stock rather than individual supplies. This practice was addressed during inspection, and the service confirmed it would be stopped.

However, the service now had effective systems and processes for administering and recording medicines.

Oral medicine administration was carried out by staff who had completed the required training and competency assessments.

Training in the use of a specific medicine for epilepsy requiring further training had been delivered by a qualified nurse, ensuring staff were competent and people received safe care. People were given their medicines, including time-sensitive medicines, at the right time to ensure they were effective. Staff had access to policies and procedures about managing medicines. Audits had been carried out for months which had previously been missed to identify themes and any lessons learned.