We carried out a review of the data available to us about Waterbeach Lodge on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Waterbeach Lodge, you can give feedback on this service.
Waterbeach Lodge is a residential care home providing accommodation and personal care to 27 people at the time of the inspection. The care home can accommodate up to 46 people across three separate floors. One of the floors specialises in providing care to people living with dementia.
People’s experience of using this service and what we found
Staff had improved their infection prevention and control practices in line with government guidance since the last inspection. This would help reduce the risk of cross contamination within the service.
There was organisational oversight within the service to support staff and again, this had improved since the last inspection.
Staff knew the people they supported well and demonstrated how they would use this knowledge when assisting people. There were enough suitably trained and knowledgeable staff to help support people in a timely manner. Potential new staff to the service had a series of checks carried out on them to try to make sure they were suitable to work with the people they supported.
Staff demonstrated a good understanding of how to report safeguarding concerns. Risk assessments to guide staff on how to monitor people’s individual risks were in place and updated. Staff supported people to take their prescribed medicines safely. Lessons were learnt and shared with staff when improvements were needed to help reduce the risk of incidents recurring.
Staff worked with external health professionals. This helped make sure people received joined up care and support. People and their relatives were asked to complete surveys to feedback on the service provided by staff. Suggested improvements were acted upon wherever possible.
Audits were undertaken to monitor the quality of the service provided. There was an unannounced provider audit also undertaken to promote organisational oversight 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 and update
The last rating for this service was requires improvement (published 04 March 2021) and there were breaches of regulation found. The breaches were Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People were not protected from the risk of harm caused by poor infection prevention and control measures. We also found a breach in relation to Regulation 17 (Good governance) of the Health and Social Care Act (Regulated Activities) Regulations 2014. The service had been impacted by COVID-19 and there was a lack of organisational oversight at the time.
The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulation.
Why we inspected
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions safe and well-led which contain those requirements. 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 requires improvement to good. This is based on the findings at this inspection.
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. This included checking the provider was meeting COVID-19 vaccination requirements.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Waterbeach Lodge on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
Waterbeach Lodge is a residential care home providing accommodation and personal care to 25 people at the time of the inspection. The care home can accommodate up to 46 people across three separate floors. One of the floors specialises in providing care to people living with dementia.
People’s experience of using this service and what we found
The provider’s infection prevention and control processes did not protect people and staff from the risk of harm. At the time of the inspection the service had an outbreak of COVID-19 with both people and staff affected. We found during our inspection staff were not always following COVID-19 government guidelines and good infection control practices. The provider had a lack of oversight within the service during this time. Audits undertaken had not identified that staff were not always following government guidelines around good infection prevention and control practice. This increased the risk to both people living at the service and staff.
During the inspection we required the nominated individual to complete an urgent action plan to demonstrate how infection prevention and control improvements would be made in the service. The nominated individual implemented an action plan identifying immediate improvements that would be made.
Staff had been trained in reporting safeguarding issues. Relatives told us they felt their family member was safe living at Waterbeach Lodge. However, we found that staff failed to recognise a safeguarding concern identified by the inspection team during the inspection. This meant that staff did not have enough of an understanding of how to protect people from potential harm.
Staff were not aware if COVID-19 care plans and/or risk assessments were in place for people. However, staff told us about the risk assessments in place for people’s individual risks such as poor skin integrity or being at risk of falls. They said these documents were available for them to read. Staff were given updates regarding learning from incidents and accidents at their staff meetings.
Staff went through a series of safety checks before they were deemed suitable to work at the service. At the time of the inspection, staffing levels had been impacted by COVID-19. Agency staff were used to make up any shortfalls.
Trained senior staff administered people’s prescribed medicines. The registered manager undertook regular medicine competency checks on them. However, staff did not always record in medicine administration charts using the agreed key symbols. This increased the risk of staff miss interpreting these records.
Staff told us they felt supported and relatives confirmed that communication between them and staff at the home was good. Although communication in a timely manner had sometimes been impacted by the COVID-19 outbreak.
Relatives told us they got regular information from the managers of the service about COVID-19 restrictions and updates. Staff worked with external health and social care professionals such as district nurses and the local GP practice.
Rating at last inspection
The last rating for this service was good published 10 May 2019.
Why we inspected
We undertook this targeted inspection and 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.
We inspected and found there was a concern with infection prevention and control procedures and oversight at the service, so we widened the scope of the inspection to become a focused inspection which included the key questions of safe and well-led.
We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.
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 improvement. Please see the safe 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 Waterbeach Lodge on our website at www.cqc.org.uk.
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.
We have identified breaches in relation to Regulation 12 (Safe Care and Treatment) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People were not protected from the risk of harm caused by poor infection prevention and control measures. Although improvements have been made, we have no evidence yet that these improvements will be sustained. We also found a breach in relation to Regulation 17 (Good Governance) of the Health and Social Care Act (Regulated Activities) Regulations 2014. As the home was impacted by COVID-19 there was a lack of organisational oversight at the time. Audits undertaken had not identified the concerns found during this inspection.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
People’s experience of using this service: People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. Staff worked within the principles of the Mental Capacity Act (MCA) 2005 and ensured people consented to their care.
People felt safe having their care provided by staff at the service. Risk assessments were in place to identify possible risks to people`s health and well-being. Measures were implemented to guide staff on how to reduce these risks. Staff worked in conjunction with guidance from external health professionals across different organisations to help promote people’s well-being where possible.
Dependency tools were used to determine staffing levels. This was to make sure staffing levels met the needs of the people using the service. Medicines were safely managed.
Staff knew the people they supported well. To develop their skills and knowledge staff received regular training, spot checks and supervisions. People were supported to maintain their independence and well-being. Staff promoted people’s food and fluid intake.
Staff promoted and maintained people’s privacy and dignity. People had developed good relationships with staff who had a good understanding of their needs and preferences.
People and their relatives told us staff were kind and caring. People`s personal information was kept confidential. People and their relatives were involved in discussions about their care and felt that staff and the registered manager knew them well. People told us if they had to raise any concerns, they would be confident they would be listened to and the concern resolved where possible.
People and staff told us the service was well managed. Staff felt well-supported. Audits including organisational audits were carried out to monitor the service and address any improvements required. The registered manager notified the CQC of incidents that they were legally obliged to.
Rating at last inspection; Good. (Report published 11 October 2016).
Why we inspected: This was a planned inspection to check that this service remained Good.
Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
This unannounced inspection took place on 07 September 2016.
There was a registered manager in place. 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.
Action had been taken to minimise the risks to people. Risk assessments identified risks and provided staff with the information they needed to reduce risks were possible. Staff were following the correct procedures when administrating, recording and storing medication so that people received their medication as prescribed. Staff were aware of the procedures to follow if they thought anyone had been harmed.
Staff were only employed after they completed a thorough recruitment procedure. There were enough staff on shift to ensure that people had their needs met in a timely manner. Staff received the training they required to meet people’s needs and were supported in their roles.
The 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 had completed some capacity assessments and DoLS applications. The provider could demonstrate how they supported people to make decisions about their care and the principles of the MCA were being followed. However, not all best interest decisions had been recorded appropriately.
Staff were kind and caring when working with people. They knew people well and were aware of their history, preferences, likes and dislikes. People’s privacy and dignity were respected.
Staff monitored people’s health and welfare needs and acted on issues identified. People had been referred to healthcare professionals when needed. People were provided with a choice of food and drink that they enjoyed. People were given the right amount of support to enable them to eat and drink.
There was a varied programme of activities including in- house group activities, one-to-one activities, entertainers and trips out. Staff supported people to maintain their interests and their links with the local community to promote social inclusion.
Care plans gave staff the information they required to meet people’s care and support needs.
There was a complaints procedure in place and people and their relatives felt confident to raise any concerns either with the staff or manager.
There was an effective quality assurance process in place which included obtaining the views of people that lived in the home and their relatives. Where needed action had been taken to make improvements to the service being offered.
Waterbeach Lodge is registered to provide accommodation and non-nursing care for up to 40 people. There were 33 people living in the home at the time of the inspection. The building has three floors. There is an open plan dining room and lounge area on the ground floor as well as a garden conservatory room and bedrooms. There are bedrooms on the second and third floors. There are two lifts which access all of the floors.
This unannounced inspection took place on 2 September 2015. The previous inspection was undertaken on 16 December 2014 and the overall rating for the home was good. However, improvements were required to make the home more responsive to people’s needs. During this inspection we found that although action had been taken to make improvements further improvement was still needed.
At the time of the inspection there was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the home. 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 home is run.
Care plans and risk assessments did not always give staff the information they required to meet people’s needs.
There were procedures in place which were being followed by staff to ensure that people received their medication as prescribed. The stock levels of medication were checked to ensure people had been given the right amount of medication. However there was no auditing of the medication records, or how medication had been stored to ensure they were appropriate. This meant that areas for improvement hadn’t always been identified.
The requirements of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) had not always been complied with. This meant that where people were being restricted from leaving the home on their own to ensure their safety, this had not always been done in line with the legal requirements. Staff did not have a good understanding of the principles of people being assessed as having capacity or making best interest decisions.
People felt safe and staff knew what actions to take if they thought that anyone had been harmed in any way.
There were enough staff available to meet people’s needs. The recruitment process was followed to ensure that people were only employed after satisfactory checks had been carried out.
Staff were kind and compassionate when working with people. They knew people well and were aware of their history, preferences, likes and dislikes. People’s privacy and dignity were upheld.
Staff monitored people’s health and welfare needs and acted on issues identified.
People were provided with a choice of food and drink. Special diets were catered for although this information was not always included in people’s eating and drinking care plans.
There was a complaints procedure in place and people felt confident to raise any concerns either with the staff or the registered manager.
The registered manager obtained the views from people that lived in the home, their relatives and staff about the quality of the home. The registered manager was aware of the improvements that were needed in the home and an improvement plan had been developed and was being implemented.
We found three 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.
Waterbeach Lodge is registered to provide accommodation, care and support, without nursing, for up to 40 older people. This purpose-built, new home, opened in 2013, is set in extensive grounds and accommodation is provided on three floors. All bedrooms are spacious single rooms, each with an ensuite shower room and there is a large, open-plan lounge/dining room on the ground floor.
This inspection took place on 16 December 2014 and was unannounced. There were 37 people in residence.
The last inspection of this service was on 19 June 2013. The provider was meeting six of the seven regulations we inspected. The provider was failing to ensure that fire safety procedures were in place as required. In October 2013 we carried out a review of the evidence sent to us by the provider. We did not carry out a visit of Waterbeach Lodge as part of this review as the provider was able to demonstrate that they were meeting the regulations without the need for a visit. We judged that the service was compliant.
At the time of the inspection on 16 December 2014 there was 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.
People and their relatives and friends were complimentary about the care and support they received, they praised the staff and the environment and were confident that their views would be listened to and acted on.
The service was safe because there were enough staff on duty to meet people’s needs, thorough checks had been carried out when staff were recruited to make sure they were suitable to work at the home and staff had been trained to recognise and report abuse. People were given their medicines safely and as prescribed by their GP and any potential risks to people were managed so that the risks were minimised.
The CQC monitors the operation of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS), which apply to care services. We found that people’s capacity to make decisions for themselves had been assessed by staff trained to do so in order that the rights of people not able to make their own decisions about aspects of their care were protected.
People were given sufficient amounts of nutritious, appetizing food and drink and were supported to make choices about all aspects of their daily lives. A range of healthcare professionals visited the home when required to make sure that people’s health was monitored and maintained.
People were treated well by the staff team who respected people’s privacy and dignity and encouraged them to remain as independent as possible. Relationships between people living at the home and the staff were good and staff showed they cared about the people they were looking after.
People and their relatives were involved in planning their care. Detailed information was available for staff so that people received the care and support they needed, in the way they preferred. Complaints and compliments were encouraged and people knew who they should talk to if they had any concerns.
The service was well led and people, their relatives and the staff were given opportunities to express their views about the way the home was managed and where improvements could be made. An effective quality monitoring system was in place.
Improvements were required in the way mealtimes were organised so that people did not have to wait so long for their food and so that staff could make the meal experience more enjoyable. Although some activities, entertainments and outings had been offered, improvements were required in supporting people to have things to do on a daily basis to keep them occupied and to keep their minds stimulated.
We reviewed evidence that demonstrated the provider was compliant with this essential standard.
Staff treated people with respect and supported them to retain as much independence as possible. Care plans gave guidance to staff so that people's needs were met and people saw other healthcare professionals so that their health was monitored.
The home was clean and hygienic and medicines were handled well so that people were given their medicines safely and as they were prescribed.
Recruitment of staff was carried out efficiently so that only staff suitable to work with vulnerable people were employed. Staff received a thorough induction and training in a range of topics so that they were equipped for their role. People were consulted about the quality of the service being provided and they knew how to complain if they needed to.
However, fire safety arrangements were not adequate to ensure that the premises were safe.