CQC report explained · a residential care home
What the CQC found at Waverley
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some care plans did not describe current risks clearly, and medicines were not always managed safely. There were enough staff at the time, and safeguarding and infection control arrangements were described as effective.
- Effective?
- Requires improvement
- The home did not always document consultation with families, social workers or advocates for decisions involving people who lacked capacity. Some staff had not received practical moving and handling training from appropriately qualified trainers.
- Caring?
- Good
- No rating was given for this question in the report. Inspectors found that people received kind and compassionate care, and that staff respected privacy, dignity and individual communication needs.
- Responsive?
- Good
- No rating was given for this question in the report. Inspectors found that people were supported to make choices, stay independent, communicate with staff and take part in activities.
- Well-led?
- Requires improvement
- Quality checks had not identified several problems found during the inspection. The report says this was the third inspection where the provider and manager had not clearly demonstrated effective oversight in all areas.
What inspectors found, July 2022
Rated Requires Improvement; inspectors found kind, person-centred care, but safety, consent, medicines and leadership needed improvement.
The CQC carried out an unannounced inspection after receiving concerns, including allegations of abuse. Inspectors visited the home, spoke with people, relatives and staff, and checked care records, medicines, staff files and management records.
People were generally treated kindly. Staff supported independence, communication, activities and access to health professionals. The home was clean, infection control was effective, and there were enough staff to meet people's needs at the time.
However, some care plans did not reflect people's current risks or needs. Medicines were not always managed safely. The home did not always record consultation with families or advocates when people could not make specific decisions. Staff training and quality checks also needed improvement.
The overall rating was Requires Improvement. Safe and Effective fell from Good at the previous inspection, while Well-led remained Requires Improvement. The report says the provider must send an action plan and that CQC will continue to monitor the home.
Kind and respectful care
People received compassionate support. Staff protected people's privacy and dignity and understood their individual needs.
“People received kind and compassionate care. Staff protected and respected people's privacy and dignity.” from the report
Independence and choice
Staff focused on what people could do for themselves and supported them to take part in everyday activities and the local community.
“People's strengths were promoted and there was a focus on what they could do, so people had a fulfilling and meaningful everyday life.” from the report
Safeguarding
Staff knew how to protect people from abuse. Safeguarding concerns were reported and investigated through the appropriate processes.
“The systems and processes in place to identify, report and investigate safeguarding concerns were used effectively by the registered manager and his staff.” from the report
Health and infection control
The home worked with health professionals when people's needs changed. Inspectors also found effective infection control, clean premises and safe use of protective equipment.
“The service used effective infection, prevention and control measures to keep people safe, and staff supported people to follow them.” from the report
Care plans and risk information
seriousSome records were out of date or gave conflicting instructions about people's mobility, epilepsy or emotional distress. This could lead to unsafe or inconsistent support.
“The information in people's care plans did not always reflect the current risks to their safety.” from the report
Consent and best-interest decisions
seriousRecords did not show that families, social workers or advocates had been consulted about some decisions for people who lacked capacity. The report also found no documented best-interest meeting for sound-detecting devices in two people's rooms.
“There was no documented evidence to show people's families, social workers or advocates had been consulted.” from the report
Staff training
seriousSome staff received practical moving and handling training from people without the required train-the-trainer qualification. This left uncertainty about whether staff could support people safely.
“Staff had not always received practical training from trainers with up to date training qualifications in moving and handling.” from the report
Quality oversight
seriousManagement checks did not identify several problems with care plans, medicines, incidents and emergency evacuation records. The provider's oversight had not clearly improved despite concerns at earlier inspections.
“This is the third inspection where the registered manager and provider had not been able to clearly demonstrate effective governance in all aspects of their quality monitoring processes.” from the report
- 01How have you updated care plans so they accurately describe current risks, mobility needs, seizure information and support for emotional distress?
- 02How are you now reviewing medicines in line with STOMP, and what checks are made on medicine records and as-required medicines?
- 03How do you record consultation with families, social workers or advocates when a person cannot make a specific decision?
- 04Who now provides practical moving and handling training, and how do you check that every staff member is competent?
- 05What changes have you made to quality audits so they identify problems with care plans, medicines, incidents and emergency evacuation records?
This was an unannounced focused inspection prompted partly by concerns about alleged abuse; ratings were given for Safe, Effective and Well-led only, while Caring and Responsive were not rated in this report. This explanation was written from the published report of 22 July 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.
What inspectors found, February 2021
Rated Good overall, but inspectors found the home was not always well-led because monitoring records were not clear.
Inspectors visited on 15 and 18 February 2021. The first visit was unannounced and the second was arranged with 12 hours' notice. They spoke with people, relatives, staff and managers, and checked care, medicine, recruitment and management records.
The home was rated Good for Safe. Inspectors found enough staff, safe medicine arrangements, suitable risk assessments and effective infection control during the COVID-19 pandemic. They found no evidence that the concerns about nursing care had put people at risk of harm.
The home was rated Requires Improvement for Well-led. Audits had improved since the previous inspection, but records did not clearly show that some areas of care, including falls, had been monitored. The overall rating improved from Requires Improvement to Good, but some other question ratings were carried forward because this was a focused inspection.
Safe staffing
Inspectors found enough staff to meet people's needs. Staff knew the people they supported well.
“People were supported by adequate numbers of staff.” from the report
Safe medicines
Medicines were handled safely, including medicines that had to be given at specific times.
“Where people required time specific medicines, we saw these were given at the correct times.” from the report
Person-centred support
Staff understood people's needs and supported independence. Plans were in place to help people return safely to community activities as restrictions eased.
“People received person centred care which met their needs.” from the report
Infection control
Inspectors were assured that the home was using protective equipment, testing and other measures to reduce infection risks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Inspectors raised no specific concerns in this report.
- 01What evidence can you show that care audits are now completed and reviewed regularly?
- 02How are falls and other incidents recorded, reviewed and used to improve people's care?
- 03How is the nominated individual recording their oversight and contact with the registered manager?
- 04How will you support each person to return safely to community activities as restrictions ease?
- 05What were the ratings for Effective, Caring and Responsive at the previous comprehensive inspection?
This was a focused inspection of Safe and Well-led only; the other question ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 27 February 2021 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
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- July 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2021Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- April 2019Requires improvementdown from GoodSafe: Requires improvementEffective: GoodWell-led: Requires improvement
- June 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 7 January 2011.
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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9 live-in carers within about an hour of Lincolnshire
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.
8 can care for a couple. 10 years' experience on average.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
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.