The Oaks Residential Care Home

The Oaks Residential Care Home provides personal and nursing care in one adapted building for up to a maximum of 30 people aged 65 and over, including people living with dementia. At the time of our inspection there were 21 people using the service.

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

People’s relatives told us they felt their loved ones received good care and were safe. Staff showed compassionate care and warmth when interacting with people, however care was delivered intuitively and not driven by best practice.

The lack of maintenance of the environment, including people's bedrooms and en-suite facilities compromised people’s dignity and did not show respect. The standards of hygiene and infection prevention and control (IPC) measures were poor, which placed people at risk of acquiring infections and associated implications to their health.

Risks to people's health, welfare and safety had not been adequately assessed and managed which placed them at risk of harm. This included failure to identify the risk to people from unguarded radiators, a window with no restrictor and insufficient information to ensure people could be safely evacuated in the event of a fire.

Staff had not been provided with training they needed to meet the specific needs of people using the service. This included, how to support people with dementia, and associated behaviours, in a positive way and those at risk of choking or aspirating when eating and drinking. This could have serious consequences to their health and put them at risk of avoidable harm.

Induction of staff, especially those new to care did not ensure they were adequately trained to carry out their roles. Recruitment practices needed to improve to ensure all relevant documentation was obtained, and available for inspection to ensure fit and proper staff were employed to work with people using the service.

Staff were not routinely provided with the appropriate supervision and appraisal to enable them to carry out the duties they were employed to perform and ensure they were competent to meet people’s specific needs.

There was not enough skilled and experienced staff deployed throughout the day to meet people’s needs and keep the service clean. Staff told us early morning and evenings needed additional staff to ensure they had time to provide personal care to those who required 2 staff, as well as ensure people in communal areas were safe.

People’s medicines were well managed. However, improvements were needed to ensure protocols were in place to guide staff when to administer medicines prescribed to relieve anxiety, on an as needed basis and ensure these were only administered as a last resort. Where people lacked capacity to consent to their care and medicines, relatives had been involved in making decisions in their best interests. People were supported to have maximum choice and control of their daily lives and staff supported them in the least restrictive way possible and in their best interests.

The service was not well-led, and governance and oversight systems were poor. Staff were aware the provider had a set of values they should adhere too, to deliver good care, but were not clear what they were. There was no effective system in place to check staff understood these values and ensure they were embedded into practice, and staff morale was low.

Systems to assess and monitor the quality and safety of the service were ineffective. Auditing processes did not provide an accurate overview of the service; ensure proper monitoring and review, identify shortfalls or inform an ongoing plan for improvement. Whilst it is recognised the registered manager took immediate action to make improvements, the governance arrangements had failed to identify the compromised quality and safety of the service.

There were no formal systems or processes in place to ensure incidents and accidents were reviewed and monitored to make sure action was taken to protect people, promptly escalate concerns to the relevant external bodies, such as safeguarding, remedy the situation or make improvements to prevent further occurrences.

Rating at last inspection and update

The last rating for this service was good (published 01 April 2021). Prior to this inspection this service has been rated requires improvement or inadequate for the last five consecutive inspections.

Why we inspected

This inspection was prompted by a review of the information we held about this service. We received concerns in relation to poor infection prevention and control (IPC), the environment, staffing and the management of the service. As a result, we undertook a focused inspection to review the key questions of safe, caring and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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 changed from good to inadequate based on the findings of this inspection. The improvements made at the previous inspection in March 2021 had not been sustained and we have found evidence that the provider needs to make improvements. Please see the safe, caring and well led sections of this report.

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

Enforcement

We have identified breaches in relation to safe care and treatment, staffing, recruitment of staff and governance arrangements at this inspection. You can see what action we have asked the provider to take at the end of this full 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 request an action plan from the provider to understand what they will do to improve the standards of quality and safety. 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.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

The Oaks is a residential care home providing personal care for up to 30 people aged 65 and over including people living with dementia. At the time of the inspection 15 people were living in the service.

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

The provider had made improvements to the systems in place to monitor the safety and quality of the service. Relatives and staff spoke positively about the changes made under the current registered manager and the atmosphere in the home. The provider was continuing to implement a redecoration and improvement plan for the service.

Risks to people’s safety had been assessed and environmental improvements had been made. The provider was in the process of updating their care planning system to improve how information was recorded.

The provider had introduced a system for monitoring staffing levels and relatives and staff told us there was enough staff available to meet people’s needs. Staff had received training relevant to their role and the registered manager monitored this.

The provider had involved people, relatives and staff in giving feedback on the service. Staff told us they were able to raise concerns and felt listened to.

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 September 2019) and there was one breach of regulation.

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 2 July 2019. A breach of legal requirements was found.

We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

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 ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from Requires Improvement to Good. This is based on the findings at this inspection.

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

Follow up

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.

The Oaks is a residential care home providing personal care to 17 people aged 65 and over at the time of the inspection. The service can support up to 30 people.

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

The service did not have appropriate and detailed evacuation plans in place for staff to follow should there be an emergency at the service.

Improvements to the environment had been made to the service since the last inspection, however further improvements were still required. We have recommended a maintenance schedule is implemented to address environmental improvements at the service.

Staffing levels had not been assessed appropriately in line with people’s needs. People and staff told us there were not always enough staff available.

We recommend the provider reviews dependency scores for people to ensure staffing levels are appropriate

Staff lacked confidence in the manager and did not feel the service was well led. The service lacked oversight by both the provider and manager, meaning issues were not always identified and managed appropriately.

End of life planning required further development. We have made a recommendation about end of life care planning.

People could take part in a range of activities during the morning , however there was a lack of stimulation in the afternoon for people.

Staff were recruited safely, were visible in the service and responded to people quickly.

People's health was well managed and there were positive links with other services to ensure that individual health and nutritional needs were met.

People received their medicines when they needed them.

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 25 July 2018). The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

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

Follow up

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.

We carried out a focused inspection within the six months timescale because we received further information of concern from the local authority and whistle blowers, which related to poor staffing levels and poor care. We inspected the key questions of ‘Safe’ and ‘Well-led’ and found that sufficient improvements had not been made since our last inspection in August and September 2017 and the provider was continuing to fail to meet the requirements of the regulations, commonly referred to as The Fundamental Standards of Quality and Safety.

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

We undertook this comprehensive inspection on 19 June 2018 to check that the registered provider had made the required improvements and to confirm they now met legal requirements.

The Oaks is a residential care home that provides personal care for up to 30 older people, including people living with dementia. There were 12 people living in the service when we inspected on 19 June 2018. This was an unannounced inspection.

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.

Since our last inspection of the service, while improvements had been made and we found no breaches of legal requirements, further improvements were still required. We viewed the steps taken to strengthen the management team of The Oaks to be a very positive step, however further improvements were still required. This to ensure that quality assurance arrangements were robust and effective to drive, sustain and embed improvements, to rebuild confidence in the service and to achieve continued compliance with regulatory requirements. We made a recommendation regarding information sharing between services and the development of a dementia friendly environment.

There were systems in place to safeguard people from abuse and the recruitment of staff was safely completed to make sure that they were suitable to work in the service. Staff were aware of their responsibilities and knew how to report any concerns.

There were procedures and processes in place to ensure the safety of the people who used the service. However, not all environmental risks had been identified and managed and improvements were required around cleanliness and decoration.

There were sufficient numbers of staff on duty to support people and meet their needs and people were provided with adequate supervision, stimulation and meaningful activity. Staff were deployed effectively to meet people’s needs.

Training for staff was managed effectively and staff had received training to equip them with the skills and knowledge required to carry out their role. Staff demonstrated an understanding of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS.) People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible.

The culture within the service had improved and people were provided with support to meet their assessed needs. However, further improvement was required to ensure that people’s mental health and emotional needs were met.

The managerial oversight in the service had improved and the management team were more pro-active. Audit and monitoring systems were in place to ensure that the quality of care was consistently assessed, monitored and improved. However, they had not identified all of the issues that we found during our inspection. This identified that further work was needed to ensure these systems were embedded and sustained to support continuous improvement.

The Oaks is a residential care home that provides personal care for up to 30 older people, including people living with dementia. On the day of our inspection there were 17 people using the service.

We carried out an unannounced comprehensive inspection of The Oaks Residential Home on 24 and 31 August and 26 September 2017, and we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service was given an overall judgement rating of 'inadequate' and is therefore in Special Measures.

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

The service had no registered manager in post. However, a new manager who intended to apply for registration had started work at the service the day before 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 legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Following our inspection in August and September 2017, we took immediate enforcement action to restrict admissions to the service. We placed conditions on the provider’s registration requiring them to demonstrate that the numbers, skill mix and competency of all staff was appropriate for the care and support needs of people living at the service. This inspection was undertaken within the six months timescale because we received further information of concern from the local authority and whistle blowers, which related to poor staffing levels and poor care. Because of this, we wanted to check that the enforcement action, which had been taken, was resulting in improvement.

This inspection focused on the areas of safe and well-led. We found that sufficient improvements had not been made since our last inspection in August and September 2017 and the provider was continuing to fail to meet the requirements of the regulations, commonly referred to as The Fundamental Standards of Quality and Safety.

There were insufficient numbers of staff on duty to meet people’s care and support needs. People’s care had not been co-ordinated or managed to ensure their specific needs were being met safely. People were not protected from the unsafe management of medicines.

Robust and sustainable audit and monitoring systems were not in place to ensure that the quality and safety of care was consistently assessed, monitored and improved. Failures in the service continued to be widespread and demonstrated the provider’s inability to make and sustain improvements.

The Commission is currently considering its enforcement powers. This includes taking action in line with our enforcement procedures to begin the process of cancelling the provider’s registration.

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.

At our last inspection in June 2016 we found that the registered provider was in breach of three regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We asked the provider to submit an action plan to tell us how they intended to make the required improvements. At this inspection we checked whether these improvements had been made and found that the provider continued to be in breach of these regulations. Additional multiple breaches of the regulations were also found.

There was a lack of managerial oversight at all levels and leadership was not pro-active. The culture within the service did not promote a holistic approach to people's care to ensure that their physical, mental and emotional needs were being met. Robust and sustainable audit and monitoring systems were not in place to ensure that the quality of care was consistently assessed, monitored and improved. Quality assurance systems had failed to identify the issues we found during our inspection.

There was not an effective system in place to ensure there were sufficient numbers of staff on duty to support people and meet their needs. There were not enough staff to provide people with adequate supervision, nutritional support, stimulation and meaningful activity. This had a direct impact on people’s safety and welfare.

People’s care had not been co-ordinated or managed to ensure their specific needs were being met. Risks to people injuring themselves or others were not appropriately managed. People's medicines were not being managed effectively to protect them from the risks of not receiving prescribed medicines.

The provider had not ensured the service was being run in a manner that promoted a caring and respectful culture. Although most staff were attentive and caring in their interactions with people, they were not supporting people in a consistent and planned way. They did not always respond appropriately and in a timely manner to all of people's needs.

Care plans were incomplete, inconsistent and task led. They had not been updated to reflect people’s current care needs. Opportunities to participate in activities were limited and activities provided were not personalised or tailored to meet people’s level of ability, choice or preference.

Training for staff was not managed effectively. Training records did not accurately identify gaps in training and not all staff had received training in subject areas relevant to their role. Staff demonstrated an understanding of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS.) However, this wasn’t always seen in practice. People were not supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible.

Staff were aware of their responsibilities with regard to safeguarding people from abuse. However they were concerned that they would not be supported in raising concerns and that this could have negative repercussions for them.

We identified a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following this inspection we took immediate enforcement action to restrict admissions and force improvement.

The overall rating for this service is 'Inadequate' and the service is therefore in 'Special Measures'. The service will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, it 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.

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.

Risks to people injuring themselves or others were not always appropriately managed. People felt that there were not always enough staff on duty. We observed that although staff were caring in their interactions with people there was a lack of attention to detail in ensuring all of people’s needs were met.

The provider had quality assurance systems in place which were used to identify shortfalls and to drive continuous improvement. However, these systems had failed to identify the concerns relating to the safety of some parts of the premises or poor staffing levels. Staff were not always clear on their roles and responsibilities and how they contributed towards the provider’s vision and values.

People presented as relaxed and at ease in their surroundings and with the staff. Systems were in place to reduce people being at risk of harm and potential abuse. Staff understood the various types of abuse and knew who to report any concerns to. People were provided with their medicines when they needed them and in a safe manner.

Staff were trained. However, they had not received regular supervisions to ensure they were meeting people’s needs effectively. The service was up to date with the Deprivation of Liberty Safeguards (DoLS). People were supported to see, when needed, health and social care professionals to make sure they received appropriate care and treatment.

People’s nutritional needs were assessed and met. However, the mealtime experience was not a positive one for many. People, or their representatives, were involved in making decisions about their care and support which was planned to meet their individual needs. However, there was a lack of resources, time, staff knowledge and motivation to provide people with a range of appropriate activities throughout the day.

People told us that they felt that their choices, independence, privacy and dignity was promoted and respected. However, we were concerned that people’s dignity was not always upheld in the way that they were assisted with their appearance.

Staff were compassionate, attentive and caring in their interactions with people. They listened to people and acted on what they said. Feedback from people and relatives about the staff and management team was positive.

A complaints procedure was in place. People’s comments, concerns and complaints were listened to and addressed in a timely manner. Family and visitors to the home felt that they were made to feel welcome and that management and staff were open and transparent.

You can see what actions we told the provider to take at the back of the full version of the report.

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;

Is the service safe?

We saw that the staff support given to people during moving and handling transfers was safe and supportive to people who used the service.

Where people did not have the capacity to consent, the provider had not acted in accordance with legal requirements. We found that not everyone had had their capacity to make day-to-day decisions assessed and that decisions made on their behalf were not always clearly explained. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to consent to care and treatment.

People were not protected from the risk of infection. The laundry was not clean and hygienic in line with appropriate guidance. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to the safe management of infection and cleanliness.

People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines safely. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to the safe management of medicines.

We saw records which showed that aspects of health and safety in the service was regularly checked.

Is the service effective?

People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. The records were regularly reviewed and updated. This meant that staff had been provided with up to date information about how people's needs were to be met safely and effectively.

We saw that the service had effective systems in place to ensure that people's nutritional well-being was monitored and supported.

Is the service caring?

People told us that they received the care they needed. One person said, "I know they are called carers and they really are caring.'

We noted that most staff were attentive and caring towards people who used the service. Staff spoke with people by name and interacted with them in a friendly and respectful way. People who used the service also knew the staff by name.

Another person said, 'Staff are very caring and concerned. They talk to people nicely. Some people are impatient, but there is never an unreasonable wait for anything or anyone."

Is the service responsive?

People's preferences, interests and diverse needs had been recorded and care and support had been planned and provided in accordance with people's wishes. This included noting people's religious preferences and their end of life care wishes.

The service recognised when people needed support from other professionals and took appropriate action to access services to meet their needs. A visiting professional told us that staff monitored people's well-being effectively, responded to their changing needs and provided people with safe care that met their needs.

Visitors confirmed that they were able to see people in private and that visiting times were flexible.

Is the service well-led?

The provider was able to demonstrate that some systems were in place to assess and monitor the quality of the service provided. The views of the people who used the service and staff had been sought. People's views about the service were noted to be positive. However, whilst the provider did have some systems in place to monitor the quality of the service provided, it was apparent from our inspection that the absence of robust quality monitoring maybe a contributory factor to the failure of the provider to identify non-compliance or any risk of non-compliance sooner.

We found that, while there were sufficient numbers of staff on duty, the skills mix, competence and deployment of staff at times during the inspection was not well organised. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to the provision of having suitably numbers of skilled and experienced staff employed.

One person we spoke with told us, "The home is run very well. The care you get is very good and one is always listened to. The manager will listen and address any issues you speak with them about. The manager is very vigilant with the care and oversees what goes on".

During our inspection we spoke with six people living in the home. One person told us: 'I count myself lucky to be here, I can't fault them.' People were very complimentary about the staff. One person said: 'The carers are without exception really caring.' All the people we spoke with told us that they were happy with the food. One person described it as 'excellent' and another person told us: 'They have really good cooks here and the meals are wonderful.' People looked well cared for and there was a happy and relaxed atmosphere in the home.

We spoke with the majority of people living in the home and with two relatives who were visiting at the time of our inspection. People living in the home were very complimentary about the staff. One person commented, 'The staff are wonderful. Nothing's too much trouble for them.' The relatives were full of praise for the standards of care and support that people received in the home. They told us, 'Staff are very caring, there's good interaction with residents and there's a good atmosphere in the home. The only thing that could be better would be more activities.' The manager was taking steps to improve the frequency and variety of activities by involving all the staff.

Parts of the premises were in need of repainting and refurbishment and carpets needed to be cleaned. The manager confirmed that all the issues raised during our inspection would be addressed. The manager was aware that the care records needed to be improved and that the systems for quality assurance needed further development.