CQC report explained · a nursing home
What the CQC found at Waverley Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2023
Rated Requires Improvement for the second time; inspectors found caring staff and responsive care, but safety, records and leadership remained weak.
Inspectors visited the home without notice on 16 and 18 May 2023. They spoke with people, relatives and staff, and checked care, medicines, staff and management records.
There were enough staff and people described feeling safe. Staff were seen treating people positively, and relatives praised their kindness. However, records and checks were not always complete. Problems included falls management, safeguarding, medicines guidance, staff training and monitoring of risks.
Responsive care improved to Good. People had care plans, activities and support with healthcare. Safe, Effective and Well-led stayed at Requires Improvement. The home had four regulatory breaches, and CQC issued a warning notice for poor governance.
Caring staff
People and relatives gave positive feedback about staff. Inspectors saw positive interactions and found a cheerful atmosphere.
“There was a cheerful atmosphere at the home. We received positive feedback about the caring nature of staff from people and relatives.” from the report
Enough staff
Inspectors found enough staff to meet people's needs. More staff had been recruited and agency use had reduced.
“There were enough staff deployed to meet people's needs. More staff had been recruited and there had been a reduction in agency staff usage.” from the report
Personalised activities
People were supported to keep up hobbies and interests. Care plans included their preferences and wishes.
“People were supported to maintain their hobbies and interests.” from the report
Improved responsiveness
The Responsive rating improved from Requires Improvement to Good. The home had improved its complaints records and was meeting communication requirements.
“At this inspection the rating has improved to good.” from the report
Falls and risk records
seriousFalls and accident records did not always show management review, analysis, lessons learned or the required observations after a fall. This created an increased risk that people could be harmed.
“Records relating to falls management and accidents and incidents did not always demonstrate that management oversight and analysis had taken place.” from the report
Safeguarding
seriousSome possible safeguarding incidents were not recognised or referred to the local authority. Records did not always show that concerns were properly monitored.
“Staff had not always recognised certain allegations/events were potential safeguarding incidents and therefore, had not made the necessary referrals to the local authority safeguarding team.” from the report
Incomplete care and training records
needs fixingRecords did not always show that planned personal care was completed or that staff training and support had taken place as required.
“Records did not fully evidence that staff training and support was carried out in line with the provider's policy and mandatory training/support and development requirements.” from the report
Medicines guidance
needs fixingThe home had a medicines system, but guidance for medicines given when needed and medicated patches was incomplete. Management said this was corrected after inspectors raised it.
“There was a lack of guidance on the provider's electronic medicines system in relation to medicines which were prescribed on a 'when required' basis.” from the report
Poor quality monitoring
seriousThe system for checking the quality and safety of the home was still not effective enough. This led to a warning notice for poor governance.
“An effective system to monitor the quality and safety of the service was still not fully in place.” from the report
Duty of candour records
seriousRecords did not show how the home had met its legal duty to be open and honest when things went wrong.
“Records did not demonstrate how the provider was meeting their responsibilities under the duty of candour.” from the report
- 01What changes have been made to review falls, record post-fall observations and document lessons learned?
- 02How do you now identify and refer possible safeguarding incidents to the local authority?
- 03Can you show that all agency staff checks and current staff training records are complete?
- 04What changes have been made to medicines guidance, especially for 'when required' medicines and medicated patches?
- 05How is the new electronic care management system improving care records and quality monitoring?
This was an unannounced focused inspection covering Safe, Effective, Responsive and Well-led; the Caring rating was carried over from the last comprehensive inspection. This explanation was written from the published report of 5 October 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, July 2023
Rated Requires Improvement; inspectors found caring staff, but concerns about safety, records, staffing, activities and management systems.
The inspection was unannounced and took place on 17 and 23 August 2022, with inspection activity ending on 30 September 2022. Inspectors spoke with people, relatives and staff, and checked care, medicines, staffing and management records.
The home was not always clean or well maintained. Inspectors found gaps in care records, delays with some DoLS applications, missed activities and weaknesses in infection control, staff deployment and quality checks. The home had increased cleaning hours, recruited activities coordinators and introduced an allocation system after the visits.
People and relatives spoke positively about the caring nature of staff. However, the overall rating changed from Good at the previous inspection to Requires Improvement. Safe, Effective, Responsive and Well-led were all rated Requires Improvement. Caring was not inspected at this visit, so the previous Good rating was used.
Kind staff
People and relatives described staff as caring and approachable. This was also reflected in staff comments.
“Despite the issues identified during the inspection, people and relatives spoke positively about the caring nature of staff.” from the report
Safer recruitment
The home carried out recruitment checks before staff were employed.
“Recruitment checks were carried out prior to staff being employed to help ensure they were suitable to work with vulnerable people.” from the report
PPE use
Inspectors saw staff using personal protective equipment effectively and safely.
“Staff wore PPE effectively and safely.” from the report
Healthcare access
Inspectors found that people were supported to access healthcare services when needed.
“People were supported to access healthcare services when required.” from the report
Activities and partnerships
Some activities and links with outside organisations and another care home helped support friendships and interests.
“There had been visits from Newcastle United's young people's academy, a singer, and links had been made between Waverley Lodge and another of the provider's care homes to facilitate friendships and activities.” from the report
Infection control and maintenance
seriousNot all areas were clean or well maintained, and there were outstanding actions from the Legionella risk assessment. CQC found this was a breach linked to safe care and treatment.
“Not all areas of the home were clean or well maintained and there were outstanding actions on the Legionella risk assessment.” from the report
Care records and legal safeguards
seriousCare records did not always show that planned care had been provided. Some DoLS applications were delayed, and CQC was not notified of all outcomes.
“There were gaps in people's care records which meant we could not be assured that care had been carried out as planned.” from the report
Activities and social needs
needs fixingActivities had not always happened as planned, particularly during COVID-19 and when there was no activities coordinator. Records did not show how people's social and emotional needs were met.
“Due to COVID-19 and the absence of an activities coordinator; activities had not always been carried out as planned.” from the report
Staff deployment
needs fixingStaffing levels had increased, but increased use of agency staff affected the skill mix according to several staff. CQC recommended keeping staff deployment under review.
“Several staff told us that this had affected the skill mix of staff on duty.” from the report
Management checks
seriousQuality monitoring did not reliably identify and address problems. The complaints log and duty of candour records were also incomplete.
“An effective system to monitor the quality and safety of the service and ensure people achieved positive outcomes was not fully in place.” from the report
- 01What actions from the improvement plan have been completed since the inspection, and what evidence can you show?
- 02How are you checking that all areas remain clean, well maintained and safe, including actions from the Legionella risk assessment?
- 03How do you make sure DoLS applications and notifications to CQC are submitted on time?
- 04How many activities coordinators are now in post, and how do you record that each person's social and emotional needs are being met?
- 05How are agency staff deployed, and how do you check that the skill mix on each shift meets residents' needs?
This inspection was prompted by concerns about care, infection control and building maintenance, then widened to Safe, Effective, Responsive and Well-led; Caring was not inspected and its previous Good rating carried over from 2018. This explanation was written from the published report of 10 July 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.
Every inspection of Waverley Lodge
3 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- October 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2023Requires improvementSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- September 2020Inspected but not ratedSafe: Inspected but not rated
- July 2018GoodSafe: GoodEffective: GoodResponsive: GoodWell-led: Good
- May 2017
Registered with the Care Quality Commission on 17 May 2017.
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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36 live-in carers within about an hour of Newcastle upon Tyne
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 £950 to £1,160 a week. 30 can care for a couple. 10 years' experience on average.
“Petty introduced herself to Mum every time she was caring for her and responded very quickly to Mum if she was distressed in the night.”
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.