About the service: Waterloo House Rest Home Limited is a residential care home that provides personal care over two floors for up to 41 older people, some of whom are living with dementia. At the time of the inspection 25 people were living at the service.

People’s experience of using this service:

People’s medicines had not always been well managed. The provider was reviewing their audits and checks as they had not always found the issues we had regarding medicines. Although some of their other checks had uncovered issues which had been addressed.

The service was homely, clean and tidy. Further updates were required to finish redecoration. Full use of all communal rooms and improvements to the garden area was still to complete. We made a recommendation regarding the use of the smoking room.

Risks to people had been minimised but when things had changed risks had not always been reassessed. People were protected from abuse by trained staff who would report any concerns. Accidents and incidents were recorded and monitored.

People and their relatives said that staff were kind and caring and went out of their way to help them if they could. The care delivered was person centred and people and their families were fully involved in decisions made. Plenty of activities were available and new ideas were being worked on.

A good selection of home cooked foods was available to meet people’s dietary requirements.

Complaints had been dealt with effectively, but some outcomes had not always been documented, this was to be addressed.

There was enough staff and safe recruitment procedures were followed. Staff were trained and supported.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

There had been recent changes in the management structure which relatives and staff told us were positive. Action plans for improvement were in place which showed what work had already taken place, but some further work was required.

We have identified one continued breach of the Health and Social Care Act (Regulated Activities) Regulations 2014 in connection with medicines management. Details of action we have asked the provider to take can be found at the end of this report.

For more details, please see the full report below and which is also on the CQC website at www.cqc.org.uk.

Rating at last inspection: Requires Improvement (Report published on 29 August 2018).

Why we inspected: The inspection was a planned inspection based on the previous rating.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our inspection programme. If any concerning information is received we may inspect sooner.

The inspection took place on 20 and 21 June 2018 and was unannounced. This meant the provider and staff did not know we would be coming.

We previously inspected Waterloo House Rest Home in May 2017, at which time the service was meeting all regulatory standards and rated good. The service was rated requires improvement at this inspection.

The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to a criminal investigation and as a result this inspection did not examine the circumstances of the incident.

However, the information shared with CQC about the incident indicated potential concerns about the management of risk and the accuracy of care planning documentation. This inspection examined those risks.

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.

Waterloo House accommodates a maximum of 41 people across two floors. Nursing care is not provided. There were 36 people using the service at the time of our inspection, some of whom were living with dementia.

The service had 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.

There was a lack of managerial oversight with a range of audits either not being completed or failing to identify longstanding areas of concern. We could not talk to the registered manager at the time of inspection. The deputy manager had a good knowledge of people’s care needs but did not have oversight of the management structures in place. The service was lacking direction and at risk of further deterioration due to this lack of direction.

The external consultancy firm who had been completing twice monthly visits had not identified the majority of the issues we saw on inspection.

There was a lack of analysis of when things went wrong in order to learn from these incidents and make improvements.

Risk assessments and care plans were often out of date or inaccurate, putting residents at risk. The fact that people received care from a well-established and knowledgeable care staff team meant they had not suffered significant impacts due to this lack of governance.

There were a number of instances of minor poor practice identified regarding medicines administration. These had never been identified or improved upon by the provider because there were inadequate auditing procedures in place.

Staff felt supported by their peers but staff meetings (and resident/relative meetings) had not happened for some time. There was insufficient staffing in place at the time of inspection to effectively meet people’s needs and ensure compliance with the regulations. A dependency tool had not identified the need for increased staffing despite people's needs becoming more complex.

There were sufficient cleaning staff on duty but their hours of work needed reviewing as care staff were responsible for maintain cleanliness of the premises from 2pm onwards, which had a further impact on their ability to meet people’s needs.

The service did not have an effective training matrix in place and training records demonstrated a lack of Mental Capacity Act/DoLs training. Likewise, ancillary staff such as cleaners and laundry staff would benefit from dementia awareness training. We have made a recommendation about this.

We could not be assured that people were always supported to have maximum choice and control of their lives in the least restrictive way possible because the relevant documentation was either not avai

Waterloo House is registered to provide care and accommodation for up to 41 older people. At the time of this inspection, there were 37 people living at the service, most of whom have a dementia related condition. Accommodation was split over two levels with lift access to the first floor.

This inspection took place on the 23 May 2017 and was unannounced. We previously inspected this service in July 2016 where we identified the service required improvement overall and was rated inadequate in the well-led domain. At that time, the provider was in breach of Regulation 12 of the Health and Social Care Regulations relating to the safety of the premises and of Regulation 17 relating to the governance and leadership of the service. We also issued the provider with a fixed penalty notice for failing to display their previous CQC performance rating.

This service has been 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. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate in any of the key questions. Therefore, this service is now out of Special Measures.

A registered manager was in post and this manager had not changed since our last inspection of the service. 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.

We looked at how the service had addressed the safety concerns with the premises. We saw significant improvements had been made and all of the major issues had been addressed with an extensive refurbishment programme including the replacement of defective or unsatisfactory equipment. The majority of people’s bedrooms had been redecorated and re-carpeted, with the rest planned for imminent completion. It was clear that checks to ensure the safety of the service had been completed relating to electric, gas, asbestos and legionella. Staff completed daily, weekly and monthly checks on the premises to ensure it was safe and well maintained.

Improvements had also been made with regards to the quality assurance system. The provider had supplied the Commission with a monthly health and safety audit and an action plan. We saw prompt action had been taken to address the concerns raised and any new issues which had arisen were now promptly attended to. Detailed audits to monitor cleanliness, infection control, maintenance, medicines and finances were in place and regularly monitored. We have rated the service 'Requires improvement' in the well-led domain because we want to be assured that these improvements will be sustained. We have also made a recommendation about the suitability of the registered managers office.

Everyone spoke highly of the registered manager. The improvements she had made throughout the service continued to be recognised by people who used the service, their relatives and visitors. It was apparent that the registered manager and the provider had invested a lot of time and money into addressing the previous concerns and were committed to ensuring Waterloo House was a safe place for people to live.

Established safeguarding procedures continued and all staff were aware of their responsibilities with regards to recognising and reporting any suspicions of harm or abuse. Individual risk assessments were in place to assist the staff to support people in a safe manner. Actions which staff could take to mitigate risks were clearly documented. Accidents and incidents continued to be recorded, monitored and reported to the local authority and CQC as necessary.

Emergency plans were in place and staff demonstrated their

Waterloo House Rest Home Limited provides care to a maximum of 41 older people, some of whom have a dementia related condition. There were 32 people living at the home at the time of the inspection.

The inspection took place on 7 July 2016 and was unannounced. This meant that the provider and staff did not know that we would be visiting. Two announced visits were carried out on 8 and 13 July 2016 to complete the inspection.

We previously carried out a comprehension inspection on 29 April 2015 and 1 May 2015 where we identified a breach relating to the premises and equipment. We found that the premises were not clean or well maintained. Following our inspection, we received information of concern relating to staffing levels. We carried out a responsive inspection in June and September 2015 and identified a further two breaches relating to staffing levels and the governance of the service. We also found further concerns with the premises and equipment. We rated the service as ‘Requires improvement’ and judged the ‘Well led’ domain to be ‘Inadequate.’ After both the comprehensive and responsive inspections, the provider wrote to us to say what action they were taking to meet legal requirements.

We inspected the service again on 7 and 8 and 13 July 2016 to check that action had been taken and carry out a full comprehensive inspection. We found that improvements had been made with regards to staffing. However, we identified continuing shortfalls with the safety and governance of the service.

Since 2012, the provider had been in breach of the regulation relating to the premises on five occasions. We had previously issued two warning notices in September 2012 and September 2014 with regards to the premises. Despite the provider taking action to meet the requirements of the warning notices, improvements regarding the premises were not sustained.

At this inspection, we spent time looking around the service and found concerns with the environment. One fridge in the kitchen was rusty and stained, another fridge was leaking. In addition, staff told us that there should be a guard between the cooker and deep fat fryer for fire safety. The flooring in the kitchen, office and other areas of the home was uneven and damaged which was a trip hazard and the roof leaked during heavy rainfall.

There was a quality assurance system was in place to monitor the service. We concluded however, that this was ineffective since action was not taken in a timely manner to ensure the safety of all those concerned. We also found shortfalls with record keeping relating to the management of the service and people.

We noted that the previous CQC inspection ratings were not displayed at the service in line with legal requirements. The manager told us that a person with a dementia condition kept removing the poster which displayed the ratings. We spoke with the director about this issue. He told us that this would be addressed.

There was a registered manager in post. A registered manager is a person who has registered with the 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 and associated Regulations about how the service is run.

There were safeguarding procedures in place. Staff knew what action to take if abuse was suspected. They were fully aware of the whistle blowing procedure.

Safe recruitment procedures were followed. No concerns about care staffing levels were raised by people or relatives. We observed that staff carried out their duties in a calm unhurried manner. Some staff told us that more domestic staff were required to maintain environmental standards. We observed that some areas of the home including the bathrooms were not as clean as they could have been. We made a recommendation that domestic staffing levels are reviewed to ensure that environmental standards are maintained.

The manager pr

Prior to the inspection, we spoke with a local authority’s contracts officer and safeguarding adults’ officer. We did not speak with people or relatives during this inspection since we used other methods to check whether the provider was meeting the regulation. We talked with the manager; laundry assistant; a member of the domestic staff and the maintenance man. We checked the premises and examined servicing and maintenance records.

We considered all the evidence we had gathered under the regulations we inspected. We used the information to answer the five 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 have found:

Is the service safe?

We found that improvements had been made regarding the condition of the premises and people were now protected against the risks associated with unsafe premises.

Is the service effective?

This question was not reviewed. Our inspection was carried out to check whether the provider had taken action to improve the condition of the premises. This question will be answered at a later date.

Is the service caring?

This question was not reviewed. Our inspection was carried out to check whether the provider had taken action to improve the condition of the premises. This question will be answered at a later date.

Is the service responsive?

This question was not reviewed. Our inspection was carried out to check whether the provider had taken action to improve the condition of the premises. This question will be answered at a later date.

Is the service well led?

We did not inspect all aspects of this question. A manager was in place. She was not yet registered with the Care Quality Commission (CQC) in line with legal requirements at the time of our inspection. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

The manager was due to have an interview on the afternoon of our inspection with a CQC registration inspector who would assess her ability to manage the home, according to the criteria outlined in the CQC Registration Regulations 2009.

Following our inspection, the manager successfully registered with CQC as a registered manager.

We spoke with five people and eight relatives to find out their opinions of the care and treatment at the service. One person told us, “The staff here are first class; they are really helpful and friendly.” A relative said, “It’s a family atmosphere in here. The banter’s good natured and well humoured. Everything is very respectful and caring.”

We were unable to speak to all of the people who used the service because of the nature of their condition. We spoke with staff and observed their practices to determine how care and support was delivered.

We found people’s needs were assessed and care and treatment was planned and delivered in line with their individual care plans. Relatives we spoke to were positive about the care and support people received. One relative told us, “It’s not the Ritz, but overall the care is brilliant. I’m really happy he’s there.”

We found that people were provided with a choice of adequate nutrition and hydration.

The home was clean and we saw there were effective systems in place to reduce the risk and spread of infection. One relative said, “My mum's room is always spotless."

We saw that there were suitable numbers of skilled, trained and experienced staff.

The provider had a written complaints policy and procedure that detailed the process to be followed in the event of a complaint. People and relatives told us that they felt able to raise any concerns or comments about the service and that they had no complaints to make.

At this visit, we did not speak with people who were using the service. Many people were unable to speak with us owing to the nature of their illness or disability and we saw that many people were asleep during our visit.

We walked around the premises and viewed equipment which had been refurbished or purchased since our last visit.

We found the provider was now protecting people against risks associated with unsafe or unsuitable premises. In addition, we found the provider was also protecting people against risks associated with unsafe or unsuitable equipment and that equipment was now available in suitable quantities to ensure the welfare of people.

We carried out this inspection as we had received information of concern about the care given to people who were using this service. Specifically, that people were woken up and dressed before 8am, even when they did not want to be.

On the day of our inspection, 30 people were using the service. We began our inspection at 5.50am and found that two people were dressed and sitting in the lounge at that time. One person told us, "They (the staff) always get me up." Staff told us the person had been sitting on the edge of their bed and had wanted to get up. We saw that the person's care plan documented their preference to get up early.

Approximately 6.15am, one other person was out of bed and dressed but they had done this independently. We asked if they were happy to be awake at that time and they told us, "Yes, I used to work on a farm."

Three staff had been on nightshift and they told us that no-one was woken up or dressed if they didn't want to be. We later spoke with the manager, and other staff, who provided information and examples to demonstrate that people got up and dressed when they wanted to.

At this visit, we did not speak to people who were using the service.

Twenty nine people were living in the home at the time of our visit.

As we walked around the premises, we spoke with many of them although we later spoke with five of them in detail. People told us they were happy with the care and support they were receiving at the service.

One person told us, “There’s not much to do but staff are great” and another person said, “We get plenty to eat and drink, it’s nice”.

We spoke with three visiting relatives. Their comments included, “It’s excellent care, more like a family atmosphere” and “It’s an old home but it’s the care that matters, everybody’s looked after”.

We carried out an unannounced inspection of this service on 29 April and 1 May 2015 where a breach of legal requirements was found in relation to premises and equipment.

After this inspection, we received concerns relating to staffing levels. It was alleged that due to low staffing levels; night staff were getting people out of bed and dressed after 4am. In addition, there were concerns about people’s care and welfare. We therefore undertook a focused inspection on 19 June 2015 to look into these concerns. A second announced visit was carried out on the 10 September 2015.

This report only covers our findings in relation to these issues. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Waterloo House Rest Home Limited on our website at www.cqc.org.uk.

Waterloo House Rest Home Limited accommodates up to 45 older people, most of whom are living with dementia. There were 30 people living at the service at the time of our first visit and 27 on the second.

We visited the service at 6.30am on the 19 June 2015. Although some people were up and dressed, there was no evidence that staff were getting anyone up that did not want to. Care plans documented what time people liked to rise and go to bed. We noted that some people liked to get up very early. We spoke with staff and observed their practices. We did not have any concerns about people’s care and welfare at the time of the inspection. We did however; find concerns with staffing levels, the premises and equipment and the governance of the service.

There was a 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 and associated regulations about how the service is run.

On our first visit to the home we found that not all areas were clean and some were in need of refurbishment. There were offensive odours in several of the rooms we checked. We saw that a number of beds did not have head boards and several mattresses were uncomfortable when we sat on them. We also had concerns about the condition of the bed linen and pillows. Many of the pillows were lumpy and some of the bedlinen was threadbare and mattress covers were torn. On our second visit to the home, we found that people’s bedrooms and communal areas were cleaner; however, we still had concerns with the condition and quality of individual bedrooms and shared accommodation. The quality of bedlinen in use was inadequate and we noticed that many of the rooms were without call bell leads. This meant there was a risk that people could not summon assistance when required.

We found that sufficient numbers of staff were not employed and deployed to ensure people’s safety and welfare were maintained and environmental standards were met.

On our first visit to the service, we found that no checks or audits of the service had been carried out since our last inspection. On 10 September 2015, the manager informed us that she had recommenced all audits and checks, although further work was still required. The provider was using a care consultancy agency to advise on the management of the service.

We spoke with the provider’s representatives on the second day of our inspection and advised them of the regulatory options currently under consideration. They assured us that improvements in all aspects of the service would be made and sustained to ensure that they met all the fundamental standards of quality and safety.

We found three breaches relating to staffing; premises and equipment and governance. You can see what action we told the provider to take at the back of this report.