Oasis Private Care Limited

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked at 4 quality statements in the well-led key question and identified one breach of the legal regulations. There was a lack of effective governance and where audits were completed, they did not accurately reflect the care being provided. Staff did know always know who the registered manager was. The Registered Manager was unable to provide accurate information about the service, including who received support and who they employed. We found the oversight and management of the service and governance and records systems were ineffective. Systems to monitor and improve quality and to monitor and mitigate risks had not always been implemented effectively. There was a lack of effective risk assessments and care planning to promote people’s safety. When incidents and accidents took place, these were poorly documented, and the mistakes and lessons were not being shared with staff. Staff lacked the training and support to provide medicines safely, protect them from potential abuse and offer a person-centred care experience.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The Registered Manager did not evidence they were a capable leader due to their lack of knowledge in respect of regulations and responsibilities. The Registered Manager had failed to robustly assess people's health needs and to include people in these assessments. Care records shared with staff were not always in place or were inadequate and did not equip staff to provide a high quality and safe service. We asked staff about the management of the service. Some staff told us they felt supported by the manager, however not all staff knew who the Registered Manager was and felt their concerns were not always listened to. We also heard staff had not met the Registered Manager, with some staff telling us they felt scared to raise things in fear of losing their job. Although some feedback from staff was positive, there was a lack of awareness, and concern, from staff on the absence of risk information and guidance around people’s health conditions which left people at significant risk of harm.

During the assessment, through discussions with the Registered Manager staff and reviewing documentation, we found leaders were not inclusive at all levels and did not always understand the context in which care treatment and support embodies the culture and value of the workforce. There was not a clear definition of roles within the leadership team to ensure it was always clear who was responsible for overseeing and managing delegated tasks in the service. The Registered Manager failed to evidence their understanding on the priorities and responsibilities of aspects of their role. They demonstrated a lack of knowledge of the priorities of the quality of service by failing to understand, acknowledge and facilitate the important safety aspects of care delivery, such as the management of risk, effective and safe care planning and the training needs care staff required to effectively carry out their role. The Registered Manager was unclear on aspects of their regulatory role with regards to safeguarding. We could not always see where the Registered Manager had taken action or what their role was in managing the day to day running of the service. Leaders were not communicating honestly and effectively. The Registered Manager’s approach to information sharing with care staff was poor. During the assessment, the Registered Manager advised they were providing a regulated activity for 4 people. However, when documentation was reviewed, 10 people were seen to be receiving a regulated activity. This lack of transparency and clarity meant it was very difficult to confirm whether people were involved in managing their risks and whether people’s needs were being met. We found staff lacked direction and guidance. This had resulted in a lack of consistent work and approach. As a result, some people had not received the right care and treatment when their needs changed. A lack of management oversight had led to risks for people using the service.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We received mixed feedback from staff. Some staff told us there were measures in place which made them feel valued and appreciated, however were unable to state what these were. We also heard management did not value staff, at times there was favouritism towards certain staff members. There were concerns around staff members pay and use of personal time in the workday which were not considered by the Registered Manager. When complaints had been made by staff, these were not always responded to, and staff felt like they were silenced when raising concerns about their pay and work.

The Registered Manager told us how policies and procedures around people’s human rights were being followed, however there was little evidence to show these were being followed and staff were being treated with dignity and respect.

The Registered Manager had failed to understand or fulfil their regulatory requirements and notify CQC of safeguarding concerns. The Registered persons are required to notify CQC of certain incidents, events and changes that affect a service or the people using it, such as abuse or allegations of abuse. We were told staff competencies relating to medicines were not within the office but elsewhere. The deputy manager obtained people's records and information. The Registered Manager is responsible for maintaining and overseeing documentation however they were unaware of where information was stored. There was a lack of robust arrangements for the availability and integrity of records and data. Staff we spoke to felt their concerns had not always been actioned by the office staff when reporting issues around care and work. Staff were aware of who to speak with to raise a concern. However, staff were not always being given accurate information about risk management and what people's needs were.

Systems to monitor and improve quality and to monitor and mitigate risks had not always been implemented effectively. This meant complaints, accidents, incidents, and other adverse events had not always been investigated or responded to completely. There were significant shortfalls in many of the records viewed. This placed people at risk of receiving unsafe care or care which did not meet their needs. There was a failure to understand the impact and importance of assessing people’s risks in full and ensuring staff had access to important information and guidance around health care conditions and risks in order to safely and effectively undertake their role. The provider was not meeting all standards of good quality care including planning of risks and care needs, and providing personalised care and support There were risks relating to medicines management and people's health and wellbeing. Therefore, people did not always receive good quality or safe care. The systems in place to ensure risks relating to people’s care and support were assessed and mitigated were not robust. The Registered Manager had limited quality assurance checks in place, the consistency and effectiveness of these were poor and had been created after the announcement of the assessment. Audits in place did not identify inconsistencies found during this assessment. For example audits did not identify issues relating to missed medicines, absent MAR charts, absent care plans, poor daily note records, lack of risk assessments, metal capacity assessments not being in place and inconsistent information throughout peoples care planning.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff feedback was not always acted upon to continuously improve the service. Within the staff survey responses, staff had recorded that they felt ‘neutral’ towards multiple issues, and one person provided a negative response. The Registered Manager stated that on the balance of probabilities staff had got the scoring wrong way around as there were no comments left. The Registered Manager made no action to follow up on these concerns to ensure that continuous improvement was made. There was no evidence to show the management team were committed to learning and improving their practices. The management team were unable to demonstrate what action they were taking to develop the service to improve outcomes and experiences for people. Good governance was not undertaken to allow future learning and action planning.

The leadership of the service did not always demonstrate a good understanding of how improvements needed to be implemented. During and following the assessment, we discussed our serious concerns about the lack of risk management around people’s healthcare conditions with the Registered Manager Although the regulatory and legal requirements were discussed and reiterated with the Registered Manager there was a lack of understanding and management of all risks to people they supported. Processes were not evidenced as being in place to ensure continuous improvement. There were no action plans in place, which would be expected following all audit processes where these identified improvements were required. The provider was not using learning to make improvements required at the service. The systems and processes for improving quality had not always been effective, they were not established or operated effectively to ensure compliance with regulations by assessing, monitoring and improving quality of service. People were placed at risk by risks which had not been identified or mitigated. For example, the way their medicines and health were being managed, and risks around missing documentation. There was not always an accurate, complete records of care and treatment provided to people. The service provided care packages to people with complex health needs which impacted on how staff safely supported them. There was a lack of training provision or guidance for staff for most of these conditions, staff did not receive robust training and their competencies had not been assessed to provide safe care. This left people at significant risk of harm.