Archived: Oaktree Care Home

People’s experience of using this service:

Since our last inspection, improvements had been made to ensure complaints were dealt with promptly with feedback given to the complainant. It was evident people felt their concerns were listened too and acted upon swiftly.

As seen at the last inspection, there was a heavy reliance on agency staff whilst the registered manager was recruiting to the vacant posts. This was having an impact on the delivery of care. People were not receiving the care when they needed or wanted it. This was in part due to the high agency usage and many of the people needing two staff to support them, which was not taken into account when calculating the staff on the nursing unit.

Staff were not being fully supported thorough regular supervisions and annual appraisals. Whilst staff had received training on a variety of topics, overall the home had not achieved the provider’s own internal compliance figures. Staff had not received training relevant to the needs of people they were supporting, such as diabetes.

Care was planned and delivered but not always in a person centred way in line with people’s preferences. This was being addressed by the registered manager, who was reviewing practice around the times when people were supported to get up for the day.

People felt safe living at Oaktree and risks to people were minimized through risk assessments. There were plans in place for unforeseeable emergencies. However, some people felt safer when supported by regular and familiar staff.

We have recommended the service review their menu planning to ensure it includes variety and all the food groups. There was a vacant chef post which was impacting on the quality of the food provision. Agency catering staff were covering the vacant hours.

People were consulted about their care and support needs and involved in decisions about their care. Staff had a good understanding of the legislation to protect people where they lacked capacity involving family and other professionals. People and their relatives told us the staff were kind and caring. Feedback was complimentary about the regular and familiar staff.

There was an ongoing decoration programme in place. The home was clean and free from odour.

There were systems in place to monitor the quality of the care and support. However, there were no improvement plans in place to ensure ongoing compliance from findings of the provider visits.

Rating at last inspection: Requires Improvement. (Report published June 2018).

Why we inspected: This was a planned inspection based on the rating at the last inspection. We saw improvements had been made since our last inspection. Our findings at this inspection have meant the rating remained Requires Improvement. This is the second time this service has been rated Requires Improvement.

Follow up: We will meet with the provider following this report being published to discuss how they will make changes to ensure the provider improves the rating of the service to at least Good. We will revisit the service in the future to check if improvements had been made.

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

The inspection was completed on the 25 April 2018 and was unannounced. The service was last inspected in February 2017 and was rated as good in all areas with no breaches in regulation.

Oaktree Care Home 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.

Oaktree Care Home is registered to provide personal and nursing care for up to 78 people. The service is divided over two separate floors. The ground floor was called Bluebell is for those who require nursing care and the upper floor is dedicated to those people living with dementia and is called Primrose. Since the last inspection, a further unit had been opened on the first floor called Snowdrop, which provided support to people living with dementia but did not need nursing care. There were 59 people living at Oaktree Care Home when we inspected.

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 2008 and associated Regulations about how the service is run.’

From our inspection, it was evident that not everyone felt their concerns were listened too and acted upon swiftly. This was because people and their relatives were not receiving an acknowledgement or a prompt response on what action had been taken to address their concerns. Some concerns were taking longer time to investigate than the provider’s complaint policy and not all concerns/complaints were recorded on the central record. This meant the provider and registered manager were unable to look for any themes. We have asked the provider and registered manager to make improvements in this area.

Concerns were raised with us prior to this inspection on how some of the equipment was maintained such as electrical appliances and pressure relieving mattresses. We saw that checks were completed on the electrical appliances annually. However, it was evident that the external contractor had missed items in people’s bedrooms and two bedrooms had not been checked. The provider has reviewed their contract with this company and new contractor has been commissioned. This was because they could not be assured all items had been checked. Assurances were provided that this would be completed the day after the inspection.

Staff completed regular checks on the mattresses with records maintained. Where the family had raised concerns, this had been addressed with actions being taken to reduce further risk. Where staff were checking floor and chair sensor mats the records could potentially indicate there was a gap in recording because there was no record to indicate that they had changed position such as moving to another area of the home or had retired to bed. Assurances were given by the unit manager and the registered manager that this would be addressed. The registered manager was aware that there were some shortfalls in recording and was addressing this through team meetings and via one to one with staff members.

People told us the staff were usually responsive to their requests for assistance when using their call bell. One person told us they had to wait, which on occasions had caused them distress. The registered manager monitors call bell response times and dependency levels of people to determine whether there were sufficient staffing in place. Because of occupancy, staffing had increased on Bluebell the nursing unit. This would ensure people’s health care needs were met as the nursing staff had been increased from one to two per shift during the morning, afternoon and evening. Staffing was kept under review in accordance with people’s dependency and occupancy.

Because of occupancy, there had been increase in agency staff being used to cover the shortfall. This was until permanent staff had been recruited and their induction completed. This was having an impact on staff morale and how responsive the service was to meeting people’s needs. In response to this, each person had an overview of their care needs in their bedroom to ensure they were supported safely and staff could respond to people’s individual needs. This meant staff had a quick guide on how to support people rather than reading the full care plan. Measures were being taken to ensure regular and familiar agency staff were being used until new staff could be recruited.

There had been some pressure on the management of the service, with the increase in occupancy, the new unit opening, reportable incidents, complaints and the ongoing recruitment of new staff. The provider had provided additional support to assist with this period and moving forward had assisted in the investigations of ongoing concerns. Assurances were provided that this was now being addressed.

We found there was a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full copy of this report.

Oaktree Care Home is registered to provide personal and nursing care for up to 78 people. The service is divided over two separate floors. The ground floor was called Bluebell is for those who require nursing care and the upper floor is dedicated to those people living with dementia and is called Primrose. There were 47 people living at Oaktree Care Home when we inspected.

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 2008 and associated Regulations about how the service is run.’

We found at our last inspection in February 2016 there were some areas the service had to improve to ensure people were safe in respect of the management of medicines and the recording of complaints. Improvements in these areas were noted. The registered persons had taken appropriate action to address these areas.

It was evident that since our last inspection the service had sustained and continued to make improvements where required. Feedback from people, their relatives and visiting health professionals was positive about the care and support that was in place. The service was well led with good leadership from the registered manager and the unit managers in ensuring these improvements continued. Staff told us they were working as a team to support people in an individualised way. Feedback from visiting health and social care professionals provided us with evidence that the staff understood and knew the people they were supporting well. This was echoed by people who used the service and their relatives.

People were safe because where their care needs had changed or an incident had occurred, appropriate action had been taken. Where incidents were identified as potential abuse; staff were reporting and an investigation was completed. This included reporting incidents and accidents to the local safeguarding team and submitting notifications to the CQC. Notifications tell us about significant events that happen in the service. We use this information to monitor the service and to check how events have been handled. People’s rights were protected and where restrictions were in place this was done with the appropriate authorisation involving other professionals. This was kept under review.

Systems were in place to ensure people were safe including risk management, checks on the environment and safe recruitment processes.

People were receiving care that was responsive and effective. Care plans were in place that described how the person would like to be supported. The care plans provided staff with information to support the person effectively. People’s health care needs were being met. Other health and social professionals were involved in the care of the people living at Oaktree. Referrals were made in a timely manner for people where required.

People’s nutritional needs were being met. Where there were risks to people there were clear plan of care in place, additional monitoring and good communication between the care and catering staff.

Staff were caring and supportive and demonstrated a good understanding of their roles in supporting people. Staff had received training and support that was relevant to their roles. This had included all staff at all levels in the working towards an accredited training programme for supporting people with dementia. Systems were in place to ensure open communication including team meetings and daily handovers. A handover is where important information is shared between the staff during shift changeovers. This ensured important information was shared between staff enabling them to provide care that was effective and consistent.

People were involved in structured activities in the home. These were organised taking into consideration the interests of the people and were organised in small groups or an individual basis. The registered manager knew that this was an area that needed improvement and was activity recruiting to the vacant activity posts. People were treated with dignity and respect and were involved in decisions about their care.

People’s views were sought through care reviews and electronic surveys. Systems were in place to ensure that complaints were responded to, and learning from these was taken to improve the service provided.

The provider had introduced systems to assess, monitor and improve the quality of care. This meant the provider and the registered manager had a better understanding of what was happening in the service and could respond to concerns or risks promptly. Where there were shortfalls the registered manager had worked with the unit managers, staff and people to develop an action plan to address these.

Oaktree Care Home is registered to provide personal and nursing care for up to 78 people. The service is divided over two separate floors. The ground floor called Bluebell is for those who require nursing care and the upper floor is dedicated to those people living with dementia and is called Primrose.

There was a manager in post. The manager commenced in post in October 2015. They had not submitted an application to become the registered with the Care Quality Commission (CQC). 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 2008 and associated Regulations about how the service is run.’

After the last inspection we took enforcement action against the provider. This was to prevent them considering any new admissions on Primrose without prior written authorisation from the Commission. There had been no admissions to Primrose since the last inspection. The regional manager, the manager and the unit manager said they felt that they were now satisfied people were receiving safe and appropriate care and would like to start to admit people to Primrose using a phased approach. The provider must contact the Commission prior to any new admissions.

There had been significant improvements since our last inspection in respect of how people were being treated, how staff were responding to their care needs ensuring they had access to appropriate professionals. There was a clear and committed management team working across all areas of the home. Staff confirmed since the last inspection there had been improvements on Primrose and they felt there were a more cohesive team which was being led by the unit manager.

There were some areas that required further improvement including the management of complaints and ensuring people received their medicines safely. This was because there was a lack of guidance for staff about ‘when required’ medicines such as pain relief and medicines to reduce anxiety. Improvements were required in respect of stock control where medicines were not given from pre-packaged ‘blister’ packs. This would mean there would be a system to pick up quickly if medicines had not been administered at the correct time.

People were supported by sufficient staff. However, it was recognised by the provider, the manager, staff, relatives and people who use the service that there was a high usage of agency staff. This was having an impact on the delivery of care because the agency staff were not always responsive to people’s changing needs. Health care professionals had seen some improvement but remained concerned that the agency staff did not always know the person well enough. Steps were being taken by the provider to recruit to the vacant staff posts.

People were safe because where their care needs had changed or an incident had occurred, appropriate action had been taken. Where incidents were identified as potential abuse; staff were reporting and an investigation was completed. This included reporting incidents and accidents to the local safeguarding team and submitting notifications to the CQC. Notifications tell us about significant events that happen in the service. We use this information to monitor the service and to check how events have been handled.

People were receiving care that was responsive and effective. This had significantly improved since our last inspection. Care plans were in place that described how the person would like to be supported. The care plans provided staff with information to support the person effectively. Other health and social professionals were involved in the care of the people living at Oaktree.

People were protected from the risk of abuse because there were clear procedures in place to recognise and respond to abuse and staff had been trained in how to follow the procedures. Systems were in place to ensure people were safe including risk management, checks on the environment and safe recruitment processes.

Staff were caring and supportive and demonstrated a good understanding of their roles in supporting people. Staff on Primrose had received training and support that was relevant to their roles. Systems were in place to ensure open communication including team meetings and daily handovers. A handover is where important information is shared between the staff during shift changeovers. This ensured important information was shared between staff enabling them to provide care that was effective and consistent. Staff on Bluebell told us they felt that all the resources and support had been given to the staff on Primrose and as a consequence standards had slipped on Bluebell. The management team were aware and were working with the unit manager and staff team on Bluebell to address their concerns.

People were involved in structured activities in the home. These were organised taking into consideration the interests of the people and were organised in small groups or an individual basis.

People’s views were sought through care reviews. Systems were not in place to ensure that complaints were responded to, and learning from these was taken to improve the service provided. This was because not all complaints we had been made aware of had been recorded.

The provider had introduced systems to assess, monitor and improve the quality of care. This meant the provider and the manager had a better understanding of what was happening in the service and could respond to concerns or risks promptly. Where there were shortfalls the manager had worked with the unit managers, staff and people to develop an action plan to address these.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

The purpose of this inspection was to follow up previous non-compliance where we identified serious failings in the home.

Below is a summary of what we found. The summary is based on our observations during the inspection, seeking experience and views from people who used the service, their relatives, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary, please read the full report.

Is the service safe?

People were protected from the risks of inadequate nutrition and dehydration. People were being supported at mealtimes so that they received sufficient amounts of food and drink that was provided to them.

The service was clean and hygienic. Appropriate guidance, equipment and facilities were in place for staff so that people were safe and protected from the risks associated with cross infection.

People lived in surroundings that were safe and promoted their wellbeing. Equipment provided to people was safe and properly maintained.

Additional cover was provided when there was any staff absence. We could not be satisfied that there were enough staff on duty. The staffing tool had been further developed and had taken into account the geography of the home, skill mix and dependency levels of people. However this was still in its pilot stage and under review.

Is it effective?

Improvements had been made to ensure people received appropriate care and support by using effective systems to assess, plan, implement, monitor and evaluate people's needs. People were now being involved throughout these processes. This ensured their needs were clearly identified and the support they received was meaningful and personalised.

Areas of additional training had been identified that were relevant to people's needs and to promote best practice. Training had been booked and some training had been completed.

Additional training, reviews of daily routines, new initiatives and equipment had helped ensure that people were receiving a nutritionally balanced diet and a sufficient fluid balance.

Is the service caring?

Staff treated people kindly and they were receiving care in a way that respected their dignity and independence. People were being supported at mealtimes with patience and by staff that were sensitive to their needs.

Additional training and care plan reviews had supported an individualised approach to care and independence was promoted.

The keyworker system and 'resident' allocation had increased staff awareness of individuals' needs. Staff we spoke with were knowledgeable about people's lives, their likes and dislikes. Efforts were being made to enhance this knowledge so that their life experiences remained meaningful.

Is it responsive?

Improvements had been made to ensure people were involved in making decisions about the care and support they received.

Appropriate referrals were made to health and social care professionals. There had been recent referrals to nutritional and dementia specialists. This had provided staff with appropriate guidance so that people were supported safely in order to minimise the risks and enhance people's experience.

It was evident that the home was making every effort to respond to the failings identified at the inspection of May 2014 in order to improve the quality and safety of service provided.

Is it well led?

In the absence of a registered manager the provider had deployed an interim manager in order to address previous non-compliance and to help support consistency and leadership in the home.

The quality monitoring systems in place had improved and were more effective in identifying where improvements were needed.

New systems had been implemented. Meetings for people and their relatives supported empowerment and effective change. The interim manager had looked at ways that staff would feel valued and be able to effect positive change and equally feel supported. Their ideas and experiences were being sought through new 'Heads of Department' meetings.

You can see our judgements on the front page of this report.

Below is a summary of what we found. The summary is based on our observations during the inspection, seeking experience and views from people who used the service, their relatives, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary, please read the full report.

Is the service safe?

The service was clean and hygienic. Appropriate guidance, equipment and facilities were in place for staff so that people were safe and protected from the risks associated with cross infection.

Is it well led?

The quality monitoring systems in place had improved and were more effective in identifying where improvements were needed.

Below is a summary of what we found. The summary is based on our observations during the inspection, seeking experience and views from people who used the service, their relatives, and the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service caring?

We found that staff we saw treated people kindly but people did not receive care in a way that respected their dignity and independence.

One person who lived in the home told us, 'Some staff just complete tasks; they go through the motions or not as the case maybe. I think this is attributed to a lack of knowledge, education and that there is not enough staff'. One staff member told us, 'I wish I could say care was individualised but we just don't have the time. We do as much as we can but I have to admit we are only able to provide the basics'. We saw that staff were rushed throughout the day.

People's personal care needs were not respected and their dignity was compromised, for example people had not been assisted to wash and dress as they would wish or helped to eat their meals. We saw people with food left in their laps following mealtimes; clothes were not always protected from spillages from food and drink.

People were not cared for in a home that was safe and clean, with poor hygiene standards throughout the home. The premises, d'cor and soft furnishings were tired and in need of replacement and repair.

Is the service responsive?

We saw that appropriate referrals were made to health and social care professionals. Staff had identified risks to people and how this would be managed. This included people that had swallowing difficulties and were at risk of choking.

People had been assessed by their GP and the speech and language therapists and staff were following the guidance so that people were supported appropriately and safely in order to minimise the risks.

Is the service safe?

People were not protected from the risks of inadequate nutrition and dehydration. This was because people were not helped at mealtimes so that they received sufficient amounts of the food and drink that was provided to them.

Because there were discrepancies around accurate recording in people's charts staff and people using the service could not be assured that food and drink intake monitoring was effective. This meant that staff may not be aware that people were at risk of poor nutrition and hydration and take any necessary action.

The service was not clean and hygienic. Appropriate guidance, equipment and facilities were not in place. This meant that people who used the service were not safe or protected from the risks associated with cross infection.

People did not live in surroundings that were safe and promoted their wellbeing. We found that equipment provided to people was unsafe and not properly maintained.

The home had less staff on duty than the manager had determined were needed to meet people's needs. Additional cover was not provided when there was any staff absence. Staffing levels did not take into account unforeseen circumstances or emergencies.

Relatives had expressed concerns about access to staff at weekends, they questioned the staffing levels in the home and they were concerned about how long people's call bells rang before they were answered.

Is the service effective?

Some care plans only contained basic information and guidance about the care and support people required. They did not show that people had been involved in developing their own care plans so that the staff could provide them with personalised care.

We spoke with two relatives who were visiting two people living with dementia. They told us, 'I have not been asked to be involved in care plans I don't know what they are' and 'It was mentioned at the relatives meeting in April that we could be involved in care plans but I haven't heard anything since then'.

People were not supported to be independent at mealtimes because they were not provided with the appropriate equipment to help them to eat.

The needs of people living with dementia had not been considered with regards to their environment. There were no signs that would help people move around independently. Equipment was stored in en suites and in communal bathrooms and toilet facilities. This meant that people could not move around freely and safely.

Is the service well-led?

We found not all aspects of the service were well-led

The home did not have a registered manager, although an application to register had been made. The management arrangements did not provide strong leadership as action had not been taken to improve the care or environment in the home. We found that the quality monitoring systems in place were not effective and had not identified improvements where needed.

This included the homes environmental audit which had failed to identify the serious concerns we found during our visits regarding the quality and safety of the environment. The audits did not identify risks to people who used the service in order to keep them safe from harm.

Staff had been employed for a number of years and it was evident that relationships with the people had been established over a period of time. Visiting relatives spoke positively about Oaktree and that they were 'happy with the care that is being provided'. The staff team were knowledgeable about people's needs and this was evident when we spoke with them.

One visitor told us they had visited the home three times before making a decision for their relative to move in. They said that on each occasion they found the home to be 'the same' and felt it was the 'best home in the area'. They described how supportive, helpful and friendly the staff were. They said their relative had 'settled well' and that staff were 'knowledgeable about how to meet their relative's needs'. They were very happy with the choice of home and added that other members of the family had expressed this to them.

Several visitors told us their relatives had previously used the home for short stay 'respite' care. They said this was the reason they had chosen to move in permanently. They expressed that they were happy with their relative's care needs being met and spoke about the 'good' communication within the home.

At this inspection we found the home to be compliant with the outcomes. Staff had received safeguarding training and knew about the importance of reporting suspicions of abuse. The home had continued to alert the local council to suspicions of abuse.

There were regular audits of the arrangements for administering medicines and where actions were identified these were responded to.

Recruitment of staff ensured there were sufficient numbers of workers to support people.

During our follow up visit we looked at the care records for six people and found them to be accurate and up to date. Assessments of needs were carried out to enable care planning. There were written comments in relation to people's care needs and monthly evaluations were completed. Where necessary care plans were complemented by charts for monitoring food and fluid intake, weight and vital signs.

We had previously felt that the lunchtime dining in the dementia unit was drawn out and not the best experience for people. During this visit we saw that alternative arrangements were in place and people were engaging with each other in a more relaxed environment.