Archived: Tall Oaks Care Home

Tall Oaks Care Home is a care home providing personal and nursing care to up to 55 people. The home was split between two floors, each with their own communal facilities, although downstairs had a larger space. The service provides support to older people who may be living with dementia or have a physical disability. At the time of our inspection there were 36 people using the service.

People’s experience of using this service and what we found

Risks to people’s health and wellbeing had not always been fully assessed and planned for. As there were a number of agency staff it was important they had access to the correct and current guidance about how to support people. There were also gaps in the recording of support some people were given so we could not be sure they were always receiving this support. Improvements were needed to the management of medicines, but the registered manager was already working on this. Systems in place to monitor the quality and safety of care had not always been effective, although the registered manager had also started putting better systems in place to improve this.

There was mixed feedback about staffing levels, and it was noted relatives and staff felt support was better when more permanent staff were working instead of agency staff. There was missing information in some staff recruitment files, although appropriate checks had been made to see what, if any, criminal convictions staff had. We were somewhat assured that the provider was using PPE effectively and safely. However, the home was clean and tidy and people and relatives told us they always thought it was without malodours. Lessons had not always been learned when things had gone wrong, but the registered manager was already taking steps to address this. There were no restrictions on visiting. People were protected from the risk of abuse by staff who understood their responsibilities and appropriate safeguarding referrals had been made.

The registered manager and management team were working hard to recruit more permanent staff. Relatives and staff felt able to go to the registered manager, if they needed to, despite the registered manager not working there permanently for very long. Staff told us they felt supported. The registered manager was aware of their duty of candour. The service worked in partnership with other organisations and professionals.

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

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

Rating at last inspection

The last rating for this service was requires improvement (published 28 September 2022). The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections.

Why we inspected

This inspection was prompted by a review of the information we held about this service. The inspection was also prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. 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 of supporting people appropriately with their health conditions. This inspection examined those risks.

As a result, we undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement based on the findings of this inspection.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘All inspection reports and timeline’ link for Tall Oaks Care Home on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to ensuring people received safe care and treatment, systems in place to monitor the safety and quality of care not always being effective and staff competency at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Tall Oaks Care Home is a care home providing personal and nursing care to up to 55 people. The home was split between two floors, each with their own communal facilities, although downstairs had a larger space. The service provides support to older people who may be living with dementia or have a physical disability. At the time of our inspection there were 44 people using the service.

People’s experience of using this service and what we found

Generally, risks to people were assessed and planned for, however one person had a missing care plan for their health condition and prompt action was not evident for one person who was not always regularly going to the toilet, which could have put their health at risk. Despite this, people told us they felt safe. People were supported to reduce their risk of choking and other risks had been assessed. Lessons had been learned when things had gone wrong. Accidents and incidents had been reviewed. Oral medicines were managed safely but recording for the application of topical medicines was sometimes poor. Some ‘when required’ medicines needed more detailed guidance, which was put in place following our feedback. There were enough staff to support people and checks were made on their suitability to work in the service. One employee needed their full employment history recording. People were protected from the risk of abuse as staff understood their responsibilities and appropriate referrals were made. People were protected from the risk of cross infection and were able to have visitors as appropriate.

Quality assurance systems had failed to identify some of the concerns we found. The provider had an action plan in place which was being monitored. Notifications were submitted as necessary. Feedback about the registered manager was very positive and people, relatives and staff felt able to approach them if needed. The registered manager understood their duty of candour. People, relatives and staff were involved in the service. The service worked in partnership with other organisations.

Staff received training to be effective in their role and felt supported. The home was in the process of being refurbished, so improvements were being made, although the home was suitably adapted to cater for those living there. People were supported to have food and drinks in line with their needs and were offered choices. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People were supported to access other health professionals when needed.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 5 August 2021) and there were breaches of regulation. At this inspection we found improvements had been made and the provider was no longer in breach of regulations, although further improvements were needed. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection. The inspection was also prompted in part by a notification of an incident following which a person using the service died. This incident is subject to initial inquiries to determine whether to commence a criminal investigation. 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 of people’s health conditions. This inspection examined those risks.

We found no evidence during this inspection that people were at risk of harm from this concern, although some improvements were needed. Please see the safe and well-led sections of the full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Tall Oaks Care Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Tall Oaks Care Home is a residential care home providing personal and nursing care for 43 people at the time of the inspection. Tall Oaks Care Home can accommodate up to 55 people aged 65 and over across two floors.

People’s experience of using this service and what we found

People’s risks were not always managed safely. Plans in place for people who required support with their nutritional needs were not always monitored, which put people at risk of malnutrition and dehydration.

Lessons were not always learnt, and quality assurance systems were not always effective in identifying the shortfalls in people’s care records. Although people had been referred to other professionals, these were not followed up, which prolonged ineffective care for people.

The majority of people were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests.

Not all staff had undergone the necessary training, which put people at risk. There were sufficient numbers of staff to meet people’s needs.

The management of medicines had improved since last inspection. However, people had access to fluid thickening powders which could cause harm if ingested.

Infection and prevention control practices were in place and in large were effective in reducing the risk of the spread of infection.

Relatives told us they felt their loved ones were safe and were kept informed of their changing needs by staff who had been safely recruited.

There was a positive culture in the home and staff felt they were supported.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 25 November 2019) and there was a breach of regulation. The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection although we found improvements had had been made in relation to the management of medicines, the provider remained in breach of regulations.

Why we inspected

We received concerns in relation to people not receiving adequate care and support. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has not changed from requires improvement. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvements. Please see the safe, effective and well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Tall Oaks Care Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to Regulation 12 (safe care and treatment) and Regulation 17 (governance) at this inspection. Please see the action we have told the provider to take at the end of this report. Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

About the service

Tall Oaks Care Home is a residential care home that provides personal and nursing care for up to 55 people. Four of the 55 beds were allocated and funded by the local Clinical Commissioning Group to assess and plan for people to return home after a hospital admission. The accommodation is provided in a single building, arranged over two floors, with communal facilities including dining rooms and lounges on both floors. At the time of our inspection 43 people were using the service, some of whom were living with dementia.

People’s experience of using this service and what we found

People were at risk of not always receiving a safe service because medicines were not always managed safely and monitoring records were not consistently completed and reviewed to assure us that appropriate action was always taken. The provider had quality assurance systems to drive improvement, but these had not identified the shortfalls we found in these areas.

People felt safe and were protected from the risk of harm by staff who understood their responsibilities to identify and report any signs of potential abuse. There was a consistent approach to safeguarding and any concerns were taken seriously and referred to the local safeguarding authority for investigation.

There were sufficient, safely recruited staff to keep people safe and promote their wellbeing. Staff received training and ongoing support to meet people’s individual needs. People had choice over their meals and were supported to access other professionals to maintain good health.

Staff had good relationships with people and always promoted their privacy, dignity and independence. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People received personalised care from staff that knew them well. People’s diversity was recognised and promoted by the staff and systems were in place to meet people’s communication needs. People had opportunities to take part in activities and social events and were supported to follow their hobbies and spiritual beliefs. Staff were proactive and ensured people received timely and dignified care at the end of their life.

People and their relatives had no complaints and felt confident raising any concerns with the staff and acting manager. There were systems in place to capture people’s views on how the service could be improved and these were acted on. Staff felt supported and valued by the acting manager and management team.

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

Rating at last inspection

The last rating for this service was Good (published 29 April 2017). At this inspection we found evidence that the provider needs to make improvements with the management of medicines and governance of the service and the overall rating has declined to Requires Improvement.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified a breach in relation to the management of medicines. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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 2008 and associated Regulations about how the service is run.

On the day of the inspection the manager was not present; however the visit was supported by the deputy manager who provided all the necessary information. We saw improvements had been made in relation to the recording of ‘as required’ medicines and prescribed medicines were managed safely and administered in line with people’s prescriptions.

People were supported to make choices and when required, assessments had been completed to ensure decisions were made in people’s best interest. The home had enough staff to support people’s needs. Any staff who had been employed had received a range of checks to ensure they were suitable to work in the home. The manager and provider had established a range of audits to support the improvements within the home. We saw feedback was sought from people, relatives and staff and any areas raised had been considered and responded to.

We found staff had established positive relationships with people. Staff showed respect for people’s choices. They ensured they maintained people’s privacy and dignity at all times. People were able to choose the meals they wished to eat and alternatives were provided. Referrals had been made to health care professionals and any guidance provided had been followed.

Staff obtained information to ensure the care reflected people’s needs and preferences. People were encouraged and supported with activities they wished to engage in. there was a strong link with the local community and people felt able to use these services within the community. Any complaints had been addressed and resolved in a timely manner.

Staff felt supported by the manager and there was a clear process in place to cascade information about the service and the needs of people. Staff had received training and felt confident to share their knowledge to improve their role.

We saw that the previous rating was displayed in the reception of the home as required. The manager understood their responsibility of registration with us and notified us of important events that occurred at the service; this meant we could check appropriate action had been taken.

Some people who used the service told us they were happy with the care they received and others expressed concerns about their care at the home. Most of the relatives of people we spoke with were pleased with the care provided at the home and told us that kind and friendly staff cared for people who lived at the home. Staff members we spoke with expressed concerns about the staffing levels and how it prevented them from providing safe care at the home.

Is the service safe?

The required health and safety checks and servicing were completed and the provider had a designated maintenance person to carry out maintenance jobs around the house. We saw that the provider had a maintenance log where staff logged in maintenance concerns and we noted that most of the concerns recorded in the book were acted on.

Prior to the inspection, we received information of concern relating to staffing levels at the home. During the inspection, people who used the service, their relatives and staff told us that the service was always short of staff. Some of the people who used the service were at risk of falling and a number of people who used the service had memory problems and were sometimes unsure of their whereabouts. We saw that people were left for long periods of time unattended or without structured activities. The service had insufficient numbers of staff on the day of the inspection.

One person who used the service was very concerned about their safety because other people who used the service kept coming into their bedroom. The person told us that they had been threatened by another person who used the service and could not do anything because of their physical disabilities. The acting manager told us that they were taking action to ensure that the person concerned felt safe, but we did not see records of risk assessments or actions taken to ensure that the person's safety was ensured.

The local authority had recently carried out safeguarding investigations relating to some people who used the service. They notified us that they had concerns that records were not completed as advised by professionals and people who used the service were at potential risk of neglect. During this inspection, we noted that people's care records were not always up to date and did not always reflect the care that had to be provided.

We have asked the provider to provide tell us what they are going to do to meet the requirements of the law in relation to ensuring the care and welfare of people who used the service.

Is the service responsive?

Some of the people who used the service told us that they had to wait for long periods if they needed assistance because the call bells were not always responded to in a timely manner. Staff we spoke with confirmed to us that there was a technical fault with the call bell system. This had been reported. The acting manager told us that the problem was reported and initial checks took place but no technical faults were identified. Further checks were planned. The service did not have a system in place for monitoring the response times to call bells.

We saw records that other healthcare professionals visited the home regularly. We saw that people were referred to other professionals when there were concerns about their health or welfare.

One person we spoke with told us that staff did not always give them their painkillers when they were in pain and requested them. We saw that people's medication administration records (MAR) did to provide clear guidance to staff on how 'as required' medication (PRN) should be administered. We also noted there was conflicting information within people's care records about how their PRN medication should be administered. This meant people were at risk of being left in pain because their medicines were not managed appropriately.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to ensuring the welfare and safety of people who used the service.

Is the service caring?

Most of the people who used the service who spoke with us told us that the staff were very good and they liked staying at the home. One person who used the service said, 'I've never seen ill things going on here'. Relatives of people told us that staff were kind and friendly.

We observed staff interaction with people who used the service and noted that the staff were friendly and treated people with compassion. All of the staff we spoke with told us that they did not have enough time to spend with people who used the service. One of the staff members we spoke with told us, 'I think carers are good but they've got so much paperwork in place that they haven't got enough time to spend with the residents and do personal care'.

We saw that sometimes, people's dignity was not always maintained. For example, when we arrived at the home in the morning, we noticed that one person was lying in bed with the door wide open and their pyjamas and bed linen soiled.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to ensuring that the dignity and privacy of people who use the service.

Is the service effective?

People's health and care needs were assessed with them and care plans were put in place but we saw that people's care plans were not always implemented by the staff. For example, one person we spoke with told us that the required assistance with their personal hygiene and care needs but they were not receiving this on a regular basis. The person's records did not show that they received the required support with their personal hygiene and care needs.

People's mobility and other needs were taken into account in relation to signage and building adaptation, enabling people to move around freely and safely. We noted that people's personal evacuation plans (PEEP) did not provide details of the level of support they required in case of an emergency.

We have asked the provider to tell us how they will ensure that people are protected against the risks of unsafe or inappropriate care and treatment arising from a lack of proper information about them.

Is the service well led?

All the staff we spoke with said that if they witnessed poor practice they would report their concerns to the manager or to the nurse in charge. Staff we spoke with did not demonstrate an awareness of how to raise safeguarding concerns or whistleblowing concerns with other authorities.

Some of the staff we spoke with told us that they did not always feel listened to or feel supported by management if they raised concerns. One staff member we spoke with said, 'If we raise a point, it'll just end up being a staff notice but no further action. We haven't seen any action for concerns we've been raising'.

The service had a quality assurance system. The audits carried out did not systematically ensure that potential risks were identified and dealt with in a timely manner.

The provider had a complaints procedure and a complaints log in place. We did not see records of complaints or concerns raised with the provider. The service did not routinely keep a log of informal complaints and concerns raised by people who used the service.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to ensuring that they have effective systems designed to enable them to protect people who use the service against the risks of inappropriate or unsafe care.

Staff were helpful, polite and friendly and there was a pleasant homely atmosphere in the home. People we spoke with felt that their needs were met by staff who were responsive and caring but some people felt there could be more attention to detail, a visitor commented,"It's the little things that don't always get done."

The provider had developed the home to include the provision of a unit dedicated to meeting the needs of people with dementia. People's nursing and care needs were met well here but the provider may wish to review how they meet people's individual social and therapeutic needs. The manager explained that the provider would be introducing the "pearl programme" which is a programme run by the company in order to improve the quality of care and support delivered to people with dementia care needs.

People who used the service were protected from harm and their human rights were respected and upheld.

There was a skilled and competent staff team working at the home and staff felt supported by the manager.

The service was well-led and there was a robust quality monitoring system in place which ensured that people received safe quality care.

We found that people who used the service were happy with the care and support they received. They said, "The care is very good here" and "I have no concerns."

We saw that people were comfortable and that staff were attentive to individual needs. People's care needs had been met, people had been supported to take their meals and drinks, and there was detailed documentation to support this.

We identified that half of the total number of people now accommodated in the home had dementia and other related mental health needs. The layout of the home was not conducive to meeting everyone's needs and the manager explained that there were plans in place to re-organise the home in order to address this.

Staff had received training to meet the needs of people who used the service and the provider had plans in place to deliver more comprehensive training around dementia care. This will help staff to meet the more complex dementia care needs of some people.

The manager could demonstrate how changes had been implemented over the last few months in order to bring about improvements for people who used the service. Staff and the people who used the service felt supported by the manager and felt that the management style was open and inclusive.