We undertook this unannounced focused inspection on 03 December 2018 to check that the provider had followed their action plan and to confirm that they now met legal requirements in respect of regulation 17 Health and Social Care Act 2008 (Regulated Activities). This report only covers our findings in relation to those requirements.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Waterloo House on our website at www.cqc.org.uk.

Waterloo House is a 'care home' that supports people living with mental health needs. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

CQC only inspects the service being received by people provided with 'personal care'; help with tasks related to personal hygiene and eating. Where they do we also take into account any wider social care provided. The service provides care and accommodation for up to 20 people. On the day of the inspection 14 people were staying at the service.

The service is owned and operated by Vivacare Limited, who also own another care home in East Cornwall called Tremanse House.

There was a manager in post, who had just had their interview with the Commission to become the registered manager of the service. 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.

We found that action had been taken to improve the systems for monitoring the safety and quality of the service.

New monitoring checks had been devised and implemented. The provider had employed a new compliance lead who had responsibility for visiting the service on a weekly or monthly basis to meet and support the manager, carry out independent audits and feedback to the provider. In addition, the provider visited the service on a three-monthly basis to meet with staff and speak with people living at the service. This helped to monitor the overall culture and ensure that regulations were being met.

Further information is in the detailed findings below.

We carried out an unannounced comprehensive inspection on 06 March 2018.

Waterloo House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The care home provides accommodation and personal care for up to 20 people who have mental health needs. On the day of the inspection 14 people were living at the service. The provider also operates another mental health care home in Cornwall.

We carried out a previous comprehensive inspection on 21 and 22 June 2017. The service was rated requires improvement, but remained in special measures. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The 'Inadequate' rating does not need to be in the same question at each of these inspections for us to place services in special measures.

Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe.

We told the provider to make improvements to ensure people’s medicines were managed safely, and that infection control practices were implemented to help reduce the unnecessary spread of infection. We also told the provider to ensure staff received training so that they could meet people’s needs effectively, and that people’s human rights were protected. In addition, we asked the provider to improve the leadership of the service, update policies and procedures and implement an effective monitoring process to help identify when improvements were required. In line with our enforcement policy we took action to impose a positive condition on the provider’s registration, which meant on a monthly basis they were required to send us an action plan relating to infection control procedures, care plans and risk assessments.

During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures, but further improvements regarding the provider’s monitoring systems are still required.

Since our last inspection, the previous manager had left, and a new manager had been employed and had had submitted their application to the Commission to become the registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered person's'. 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’s medicines were now managed safely. People were now protected from good infection control practices. Staff had received training in infection control, and put their knowledge into practice.

People told us they felt safe. People were protected from abuse because staff knew what action to take if they suspected someone was being abuse, mistreated or neglected.

Overall, people lived in an environment which was safe. The shed in the garden now had a padlock, and items which could pose a risk within the service were locked away. However, water temperatures in three bathrooms were found to be very hot. The manager explained a new maintenance person had been employed, and one of their roles would be to ensure water temperatures are at the correct temperatures. A new monitoring system was also being put into place to help ensure the ongoing safety of the environment.

People were encouraged to take risks. Risk assessments were in place to help support risk taking, and help reduce risks from occurring. People who had behaviour that may challenge staff or others had risk assessments in place which gave good guidance and direction to staff about

The inspection took place on the 21 and 22 June 2017 and was unannounced.

Waterloo House is a care home which provides accommodation and personal care for up to 20 people who have mental health needs. On the day of the inspection 17 people were living in the service (Two people were in hospital).

At the last inspection on the 12 and 25 October and 1 November 2016 we found significant concerns relating to managing people’s care and risk, care planning, infection control and prevention, safeguarding people from harm, staff training and knowledge, the environment and leadership. We rated the service as inadequate overall. In line with our enforcement policy we made the decision to place conditions on the provider’s registration. We told the provider they must send us monthly reports to tell us about their progress to address the concerns raised. This condition will remain in place until we are satisfied sufficient improvements have been made. We found most breaches had been met but had concerns about medicine management and the governance systems within the home.

The service has also been in Special Measures. Services are placed in special measures when they have been rated as inadequate overall. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe.

The overall rating for this service is ‘Requires improvement’. However, the service will remain in special measures. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures.

At the time of the October 2016 inspection the service did not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered person’s’. 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. Following the October 2016 and at the time of this inspection, a consultancy service with mental health experience was working with the provider to support improvements at Waterloo House. The provider was actively trying to recruit to a registered manager.

Following the last inspection in October 2016 we requested that the provider send us monthly reports on their progress to address areas of concern we had found. We received reports as requested and also met with Plymouth City Council to discuss the action taken to improve the quality and safety of services provided to people at Waterloo House. The quality monitoring team for Plymouth City Council told us the consultancy team had worked closely with them and had been open and responsive when discussing the concerns found and action needed.

People and other agencies said they had seen improvements in the service during the last six months. The provider and consultancy team had spent time with staff discussing the concerns found at the last inspection and had considered what factors may have contributed to these failings. They said they had involved all the staff in these discussions and listened carefully to their views and feedback. The consultancy team said they recognised the changes were work in progress, but felt positive progress had been made so far. Staff said improvements had been made and they felt more valued and involved in decisions about the service. Staff said they were very happy working in the home. All staff were working together as a team and keen for the service to improve.

At this inspection we found improvements had been made but further work was needed in relation to infection control, medicine management, meeting staff training needs, understanding of the Mental Capacity Act (2005) and

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

This inspection took place on 12 and 25 October and 1 November 2016 and was unannounced. Day one of the inspection was undertaken by one adult social care inspector. Days two and three of the inspection were undertaken by one adult social care inspector and one specialist advisor, who had a background in nursing. The inspection was undertaken following the Care Quality Commission receiving information of concern from the local safeguarding authority and externally employed professionals visiting the service.

Waterloo House is a care home which provides accommodation and personal care for up to 20 people who have mental health needs. At the time of the inspection there were 19 people living at the service.

At the time of the inspection there was no registered manager in post. 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. A new manager had been appointed who was due to commence their role in December 2016.

Following the inspection, CQC made safeguarding alerts in respect of both the whole service, and in relation to four individual people who lived at Waterloo House.

People who used the service were not always protected from the risks of abuse. There were some instances, where people who were at risk of harm, were not reported to safeguarding authorities, or satisfactory plans were not put in place to minimise the risk of harm to others. The details kept by the service of who to contact to discuss safeguarding concerns were seen to be out of date.

People were not kept safe within the environment because infection control practices were not sufficient. There was a lack of Personal Protective Equipment (PPE) within the home, to prevent the cross infection of transmittable diseases. Where people had illnesses which may have posed a risk of cross infection to others, their care plans were out of date and lacked guidance for staff on managing the risk. We observed unsafe practices around infection control in relation to items in bathrooms, such as bath towels. Routines intended keep the home clean and protect people from the risk of c

We considered our inspection findings to answer questions we always ask;

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

This is a summary of what we found. The summary is based on our observations during the inspection, speaking with ten people using the service and three staff supporting them. We looked in depth at three care plans and people's daily records and spoke to a mental health professional who had recently visited the home.

Is the service safe?

People told us "It's safe as houses here"; "Yes, I feel safe"; "I've had nothing go missing here, not even a sock!" and "It's a nice place and I feel safe."

People were treated with dignity and respect. We spent time talking to people at the home and observed the care in the lounge for three hours. We noted that all interactions between staff and people were respectful and people's dignity was maintained. We saw in people's care files that prompt referrals for advice and support were made for people when their health deteriorated and the home acted on the advice given. People told us without exception that they felt safe at the home and that there were sufficient staff on duty to meet their needs. The staff we spoke to had a good understanding of safeguarding and understood their responsibilities to protect the people they supported.

CQC monitors the Deprivation of Liberty Safeguards (DoLs) which applies to care homes. The manager told us that they had not had to submit any formal applications but had sought advice for some people regarding their care. There were procedures in place to gain people's views and people felt that any concerns they raised were acknowledged and acted upon.

The Registered Manager set the staff rotas, they took into account people's care needs and social activities when making decisions about the numbers, qualifications, skills and experience required. This helped to ensure people's needs were always met. There were systems in place such as one to one meetings and staff training which helped to maintain safe practice.

Is the service effective?

People told us how much they liked living at the home and that they felt well looked after. A mental health professional told us that some people who had gone to live at Waterloo House had continued with their recovery and were doing very well. The staff we spoke to were knowledgeable about the people they cared for, were well trained and supported in their roles. People's care plans were individualised and considered all aspects of their health and social care. The people we spoke with told us they felt involved with all aspects of their care and that their care plans reflected their needs. We found people's care was regularly reviewed by the appropriate health and social care professionals involved. There was good communication evident through written and verbal handovers and regular staff and resident meetings.

Is the service caring?

People told us "I love all the carers"; "They spend time with us"; "I feel very safe and looked after"; "I'm well looked after"; "It's all good here".

All of the people we spoke with told us they felt happy and well cared for and that the staff were kind and responsive to their needs. Staff told us they also felt cared for and nurtured by the management team. We observed staff caring for people in a kind, unhurried way explaining to people what they were doing and the reason behind the intervention.

People at Waterloo House completed regular questionnaires about their experience of living at the home and we saw the responses were positive.

People's preferences, interests and diverse needs were recorded in their care plans and known by the staff working alongside them. This meant care was provided in accordance with people's needs and wishes.

Is the service responsive?

People completed a range of activities in and outside the service regularly. The home supported people to attend the activities they enjoyed to maintain their social interests.

People knew how to complain and who to speak to if they were unhappy. No one we spoke with had any complaints. People told us that they were confident staff would listen and act upon any concerns they might have.

The mental health professional we spoke to told us that they had been impressed by the assessment process and that the home had been flexible and responsive. The admission process involved an assessment of people's needs to ensure the home could safely care for people, visits to the home and thorough care plans developed with the individual and / or family. The staff we spoke with gave examples of how they had noticed when people's health needs had changed and they had promptly sought advice and support. Staff we spoke with who had been unfamiliar with some health conditions, had done research into specific conditions to gain a better understanding. This meant they were better equipped to meet people's needs.

Is the service well-led?

The service worked well with a variety of health and social care agencies to ensure people's needs were met. Staff told us that they understood their roles and responsibilities, felt confident to seek advice from senior colleagues and felt supported by the management team. There were regular staff meetings and staff regularly met with their line manager.

People told us "They do everything for us - washing, bills, give us nice food" and " They involve us in everything they do - like Halloween - I am going as a witch!"

During our visit to Waterloo house we met with eight people, spoke with four staff on duty and reviewed five care records and five staff files. We found people were involved in decisions about their care and treatment and staff understood the principles of the Mental Capacity Act (2005) which ensured people's human rights were respected.

Care and treatment was provided in accordance with people's needs. A holistic approach was evident in the care records which considered people's physical, mental health and social needs. Evidence of health and social care professionals involvement was apparent. Risks were assessed and updated if people's needs changed. People were able to participate in community activities as they wished.

We saw that the home was clean and well maintained which reduced the risk of infection.

Staff were well trained and supported by the registered manager and deputy manager. Regular supervision, appraisals, training and meetings were in place for staff working at Waterloo House.

There was a system in place to manage complaints and the people living at Waterloo House and the staff were confident complaints would be taken seriously and investigated.

We met and spoke to most of the people who used services, spoke to three visitors, talked with the staff on duty and checked the provider's records. One person using the service said, “A top place”. We looked at surveys sent out and returned to the home for further information.

We saw people living in the home being involved in many decisions about how the home was run, including being involved in upgrades to all living areas.

We saw people's privacy and dignity were respected and staff were helpful when assisting people. Comments from people who lived in the care home included, "They (the staff) are very kind” and “Very kind people”.

Staff were clear about the actions they would take should they have any concerns about people's safety.

We saw and heard staff speak to people in a way that demonstrated a good understanding of people's choices and preferences. We looked in detail at the care three people received. We spoke to staff about the care given, looked at records related to them, met with them, and observed staff working with them. We saw that the staff had a good understanding of people's individual needs and that they were kind and respectful. They took time to work at people's own pace.

We saw that people's care records described their needs and how those needs were met. We saw that people consent to all areas of their lives including consent to the home administering their medication.

The inspection took place on 27 September and 9 October 2015 and was unannounced.

Waterloo House is a residential home providing care, rehabilitation and support for up to 20 people with mental health needs. At the time of the inspection 20 people were living at the home.

Waterloo House has a registered manager. 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.

During the inspection people and staff appeared happy and relaxed; there was a calm and pleasant atmosphere. Comments included; “I feel like I am back home again living with my mother and sisters. I never thought I would feel like that again. That’s remarkable. I’ve never felt safer all my life. When I had my own home I was burgled several times. Here, I do feel so safe. I am very happy.” Another person told us “The best thing here is the freedom to do as you choose.”

Care records were individualised and gave people control and reflected their choices, likes and dislikes. Staff responded quickly to people’s change in needs if they were physically or mentally unwell. People were involved in identifying their needs and how they would like to be supported. People’s preferences were sought and respected for example if they preferred particular staff to support their needs.

People’s risks were managed well and monitored. People were promoted to live full and active lives and were encouraged to go out of the home and visit the local shops, pubs, parks and leisure facilities if they wished. One person told us ““There are trips out to Cornwall and they take you to all your appointments.” Activities were varied and reflected people’s interests and individual hobbies.

People had their medicines managed safely. People received their medicines as prescribed and on time. People were supported to maintain good health through regular access to healthcare professionals, such as GPs, mental health professionals (CPN’s) and social workers. People told us “They give me my medication which helps, I’m a bi polar and it stops my mind racing, keeps me on an even keel.”

Staff understood their role with regards to the Mental Capacity Act (2005) (MCA) and the associated Deprivation of Liberty Safeguards (DoLS). Advice was sought to help safeguard people and respect their human rights.

All staff had undertaken training in safeguarding adults from abuse. Staff displayed good knowledge on how to report any concerns and described what action they would take to protect people against harm. Staff told us they felt confident any incidents or allegations would be fully investigated. Where people had capacity and there were concerns about their safety if they left the home, meetings were arranged with professionals who knew people well to consider risk management strategies.

Staff described the management to be very open, supportive and approachable “I love it here. I feel so at home. We all get on like a house on fire. “X”, the manager, is amazing. She’ll come up to my room if I need her to. You can talk to her about anything and everything, and she will sort things out for you. She is brilliant, I love her to bits.” People told us the management was a visible presence within the home. Staff talked positively about their jobs telling us they enjoyed their work and felt valued. The staff we met were caring, kind and compassionate.

Staff received a comprehensive induction programme. There were sufficient staff to meet people’s needs. Staff were trained and had the correct skills to carry out their roles effectively.

There were effective quality assurance systems in place. Incidents were appropriately recorded, investigated and action taken to reduce the likelihood of reoccurrence. People knew how to raise a complaint if they had one. One person said “No complaints – I’d talk to staff if I had any.”

Feedback from people, friends, relatives, health and social care professionals and staff was positive; and people felt listened too. Learning from feedback helped drive improvements and ensure positive progress was made in the delivery of care and support provided by the home.