Waterloo House Rest Home Limited

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Systems were in place to assess and mitigate risks, however some risk assessments would benefit from more detail. People told us they felt safe and were cared for by staff who knew them well. There was a culture of openness and learning from incidents and concerns to improve the quality of care provided. Processes were in place to ensure the safety of the premises and equipment. Audits of medicines records had not been completed and they were not always accurate and up to date. We found no evidence of impact on people and the management team agreed concerns would have been picked up if audits were completed.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Overall, people and their relatives were positive about the care they received. We were told staff were kind, friendly and looked after people well. People said staff were never rude or rushed people and worked well as a team. There were no specific comments made by people about the culture.

A culture of openness and honest communication had been developed with a focus on staff knowing people really well. Concerns were listened to, and lessons were learnt to improve the quality of the care people received.

Processes were in place to investigate and learn from incidents, improve the quality of care people received and share the learning with the staff team. This included referring people to other professionals for support, such as the behaviour support team, and identify triggers for anxiety and falls.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

The staff and management team spent time getting to know people so they could understand their needs and preferences whilst balancing this with the identification, assessment and mitigation of risks. People, and their relatives told us they were involved in care planning and received good care.

Staff understood the processes to identify, assess and mitigate risks and involved people in all aspects of care planning and reviews. Staff were conscious of the need to ensure people were supported in a safe way whilst maintaining their independence and choice.

Staff were observant to risks and supported people in a way which was safe and enabled people to do the things that were important to them. Staff supported people with mobility needs to transfer from wheelchairs to comfortable seating in a safe and sensitive way.

Processes were in place to assess and manage risks. However, some risk assessments would benefit from more detail, and they were not always person-centred. For example, a behaviour care plan included the behaviour the person displayed but there were no clear strategies for staff to follow to distract the person and manage their behaviour if it escalated.

People were happy with the environment. Multiple people commented on the redecoration and updates that had happened recently saying that they, “liked the décor”.

Regular audits of the environment were completed, and action taken to improve the décor and ensure equipment was safe for its intended use. Staff told us they are encouraged to recycle and turn lights off when safe to do so, they also told us about recent fire training and fire evacuation plans.

No concerns were noted in relation to the environment or the use of equipment. The home was noted to be clean and tidy and work was in progress in relation to improving the environment for people. Fire exits were clear of obstructions and fire evacuation equipment was available.

Processes were in place to make sure appropriate safety checks and servicing of equipment was in place. There had been a delay in the timely completion of the five yearly Electrical Inspection Condition Report however this had now been completed. A health and safety and infection prevention and control action plan was used to drive improvements and actions identified during a recent fire service inspection were being completed.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

The environment was visibly clean and tidy, and some recent refurbishment work had been completed. One person commented the environment was safe and clean, and others told us they were happy with the work that had recently completed in the home.

Staff had attended training in infection, prevention and control and health and safety.

There were no concerns noted in relation to infection prevention and control. The home was visibly clean and personal protective equipment (PPE) was available for staff to use as needed. We observed one instance of PPE not being stored correctly but this was rectified immediately.

An infection prevention control action plan had been developed in March 2024 which included actions needs in relation to decoration and flooring. A named person was included in the plan for completing the works as soon as possible. A health and safety action plan was in place. Work had been completed in relation to the drains and other work needed was marked as urgent.

People told us their medicines were managed well. They said medicines were administered on time and changes were discussed with them. One relative said, “To our knowledge there has been no problems with medication” and another commented.” A person said, “They come round with medicines, sometimes they wake me up in a morning to give me my tablets.”

Staff had completed training in the safe administration of medicines and said they felt competent to do so. The management team commented on the ‘resident of the day’ process replacing medicines audits and agreed audits would have been more effective in identifying areas for improvement within medicines records.

Processes were in place for the safe administration of medicines, however we identified shortfalls in medicines records. Medicine risk assessments and care plans were not always detailed, and risks had not always been mitigated. Protocols for the administration and monitoring of ‘as and when required’ medicines were not always in place and the administration of creams was not always fully recorded. We also found two people had some gaps in the administration of their medicines however there had been no impact on people’s health. The management team confirmed a daily balance of medicines stock was completed but they had stopped completing medicine audits, when a resident of the day system was introduced. We discussed the concerns we had found in relation to medicines records and the management team agreed the concerns should have been identified in audits. This was an area for improvement.