CQC report explained · a residential care home
What the CQC found at Watermoor House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, May 2023
Watermoor House is rated Requires Improvement; inspectors found kind care and safe medicines, but important risks, recruitment checks and records were not always managed properly.
This was an unannounced inspection on 22 and 23 March 2023. Inspectors spoke with people living in the home, relatives, staff and a healthcare professional. They observed care and checked care records, medicines, recruitment files and management records.
The home was not always safe. Some staff did not understand important risks, including seizures, choking, thickened drinks and falls. Care records did not always contain current instructions. Safe recruitment checks were also incomplete.
The home was not always well-led. Audits had not reliably found or corrected problems with recruitment and care records. A new manager had started shortly before the inspection and had already identified the need for improvements.
The overall rating remained Requires Improvement, as did Safe and Well-led. The inspection did not examine the circumstances of a person's death that had prompted further CQC investigation. It found no evidence that the identified shortfalls had affected people's care.
Kind, caring staff
People and relatives described staff as kind, caring and friendly. They said staff knew people's preferences and provided the care they needed.
“The staff are good and kind and try to do their best” from the report
Medicines
Inspectors found that people received their medicines safely as prescribed. Staff who gave medicines had training and competency checks.
“People received their medicines safely as prescribed.” from the report
Safeguarding
Staff understood how to report concerns about abuse and said they felt confident doing so. Relatives said people felt safe in the home.
“People were protected from the risk of abuse by staff who knew and understood the provider's safeguarding policies and procedures.” from the report
Infection control
Inspectors were assured that the home had arrangements to prevent and manage infections, including the safe use of protective equipment.
“We were assured that the provider was responding effectively to risks and signs of infection.” from the report
Incomplete risk plans
seriousPlans for seizures, choking, thickened drinks and falls did not always give staff enough current information. Some staff could not explain the correct actions, creating a risk of harm.
“Effective systems had not been fully implemented to assess and mitigate risks to the health, safety and welfare of people using the service.” from the report
Recruitment checks
seriousReferences from previous care employers were not always obtained. The home did not always record how risks were assessed when employment checks were incomplete.
“Safe recruitment practices had not always been followed. This placed people at risk of harm.” from the report
- 01What has been changed in the care plans for people at risk of seizures, choking, unsafe drinking or falls?
- 02How do you check that every member of staff understands each person's current risks and required actions?
- 03How do you make sure references and employment-history checks are completed before new staff start work?
- 04What evidence can you show that audits now identify and correct missing or out-of-date care records?
- 05How are care plans reviewed after a fall, accident or other incident?
This was an unannounced focused inspection of Safe and Well-led, including infection control; the other key-question ratings were not inspected during this visit, and the circumstances of a reported death were not examined. This explanation was written from the published report of 11 May 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, November 2022
Watermoor House is rated Requires Improvement; inspectors found caring support but unsafe recruitment and incomplete care records.
This was an unannounced inspection on 13 and 14 September 2022. Inspectors observed care, spoke with people, relatives, staff and a healthcare professional, and checked care, medicines, recruitment and management records.
People and relatives said they were happy with the care and felt safe. Inspectors found medicines were managed safely, staff understood people's needs, infection control arrangements were in place and people were supported with their choices.
However, some recruitment checks had not been completed properly. Care records did not always contain up-to-date risk information or show that planned care had been delivered. The home's own checks had not always found these problems.
The overall rating changed from Good at the previous inspection, published in October 2020, to Requires Improvement. CQC found breaches relating to safe recruitment and good governance, and asked the provider for an action plan.
People felt safe and happy
People and relatives gave positive feedback about the care. They said people were safe, well looked after and had things to do.
“People told us they feel happy living at Watermoor House. People's relatives were complimentary about the care their loved ones received.” from the report
Medicines were managed safely
Staff who administered medicines were trained, records were signed correctly and audits checked that medicines were given as prescribed.
“People's medicines were kept secure and administered safely by staff who were trained.” from the report
Safeguarding and choice
Staff understood how to report abuse. The service was working within the Mental Capacity Act and used best-interest processes where needed.
“People were protected from the risk of abuse by staff who had the knowledge and understanding of the provider's safeguarding policies and procedures.” from the report
Infection control
Inspectors were assured that the home had arrangements to prevent and manage infections, including the safe use of protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
Positive relationships
People, relatives and staff described an approachable, caring culture. Relatives said communication and family involvement were good.
“People and their relatives spoke positively about the staffing team and the caring culture.” from the report
Incomplete recruitment checks
seriousSome required checks and references were missing. Employment gaps and the risks of missing information were not always properly assessed before staff were employed.
“Safe procedures were not followed when new staff were recruited to ensure they were safe to provide care to people.” from the report
Audits did not find problems
needs fixingThe home's checks did not always identify weaknesses in recruitment records and care records. CQC said the systems were not robust enough to demonstrate that safety was being managed effectively.
“People's care records had been audited however these were not always effective in identifying the record shortfalls we have found during the inspection.” from the report
No registered manager in post
needs fixingThere was no registered manager at the inspection. A new manager had been recruited and was due to start.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01Have all staff now had the required employment, reference and suitability checks, including checks covering gaps in employment history?
- 02How are you checking that every person's risk plan is current, especially where there are choking, hydration, mobility or repositioning risks?
- 03How do daily records show that each person's planned care has been completed?
- 04What changes have been made to audits so they identify recruitment and care-record problems before they put people at risk?
- 05Has the new manager started, and who is responsible for the home until the manager is registered?
This was a focused inspection of Safe and Well-led; the other key-question ratings were not inspected during this visit and were carried over from the previous inspection. This explanation was written from the published report of 2 November 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Watermoor House
5 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- May 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- October 2020Goodup from Requires improvementSafe: GoodWell-led: Good
- October 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Inadequate
- December 2018GoodSafe: GoodWell-led: Good
- May 2018
Registered with the Care Quality Commission on 31 May 2018.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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38 live-in carers within about an hour of Gloucestershire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,030 to £1,360 a week. 31 can care for a couple. 12 years' experience on average.
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Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.