Ocean Hill Lodge Residential Care Home

On this page

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. This is the first assessment for this newly registered service. We identified evidence contributing to 3 breaches of regulations; staffing, safe care and treatment and governance. There were not enough staff to provide consistent care in line with people’s needs and preferences. Staff had not completed recent moving and handling training. Medical and safeguarding concerns were not escalated. Accidents and incidents had not been reviewed to identify learning or areas for improvement.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There had been changes to the management of the service. One registered manager had recently left the service. The remaining registered manager did not have a good understanding of people’s needs. They were unfamiliar with the systems and processes for monitoring the service’s performance. A relative commented, “It’s a nightmare at the moment, there is so much to do.”

Staff had not been given opportunities to develop skills. Staff told us they had not received updated face to face moving and handling training. One commented, “It’s been ages, at least a couple of years.” Another said, “I recently did the on-line training and realised I’d been doing it wrong, I didn’t know.”

Systems to support learning from incidents were not robust. Incidents and accidents were recorded. However, the registered manager did not have oversight of the information. No audits were completed to enable them to identify patterns and trends.

When staff had concerns for people’s health and well-being the information had not always been shared with other agencies.

The registered manager did not have a system for admitting new people into the home. They relied on information from other agencies. Four people who were relatively new to the service did not have care plans. During the assessment process it was clear the current registered manager did not understand the service’s system for assessing and identifying people’s needs.

Due to concerns about the service's performance the local authorities quality improvement team had been providing support to the provider.

The service worked with other agencies to provide joined up support for people. However, the gaps in records and failure to escalate concerns did not support effective information sharing.

Safeguarding processes were not followed. Staff had recorded that 1 person had bruising to their arms and scratches on their back. No action had been taken to investigate the possible cause of the injuries. The registered manager was unaware of the situation.

Five members of staff had not completed safeguarding training. Staff told us they would not know how to raise concerns outside of the organisation. Some staff were unsure how they would raise a concern internally. One commented; “Before I would have told the manager, but we don’t have one now.” Although there was a registered manager in place this member of staff did not fully understand their role.

One person who was cared for in bed was often left alone for long periods of time. Although a call bell was available, they were unaware of this and told us they did not have a call bell. We heard this person calling out. When we brought this to the attention of staff they replied, “Oh yes, they do that.”

Systems to protect people from the risk of financial abuse were not effective. One person had a pre-payment card in their care files. The PIN was written and highlighted on a piece of paper kept with the card. The service was looking after some people’s personal monies. Security measures were not robust. The registered manager did not have a good understanding of the Mental Capacity Act MCA and associated Deprivation of Liberty Safeguards (DoLS). Some people had been assessed as lacking capacity to make specific decisions and Deprivation of Liberty Safeguards (DoLS) applications had been submitted on their behalf. Accurate records were not available, detailing who DoLS application had been made for. One person had conditions on their DoLS authorisation that had not been adhered to. There was no system for monitoring restrictions within the service. The DoLS team had not been made aware one person was having their medicine administered covertly.

Risk assessments had not been completed for some people who had recently moved into the service. This meant staff did not have the information they needed to support people safely. A member of staff told us recent training had highlighted how they should try and encourage people to get up from a chair independently. They commented; “I’ve been helping them up rather than encouraging them, I’ve been taught wrong.”

We were not confident the registered manager knew how to safely manage risk. They had no experience of producing risk assessments. One member of staff told us they had not had an opportunity to read care plans when they started work at the service.

We observed the lunchtime period. Staff were not deployed appropriately to enable people to eat safely at lunch time. There was only one staff member in the dining room to support 16 people. One person repeatedly got up from their chair as they wanted to leave the room. The one member of staff in the room at first tried to persuade the person to stay in their chair. Eventually they supported the person to leave the room. However, this left the remaining 15 people unsupervised.

On the first day of our assessment 4 people did not have any care plans or risk assessments in place to highlight to staff when they needed additional support. The registered manager told us they were waiting for the deputy manager to return from leave to complete these as they had no experience of doing them. Records showed there had been occasions when people had fallen and banged their heads. These incidents had not been escalated to medical professionals as directed by the service’s head injury protocol.

During the assessment period the boilers in the service malfunctioned and at times there was no heating and/or hot water. The registered manager purchased heaters and extra bedding to help ensure people were warm and comfortable. However, no risk assessments were developed in relation to the use of portable heaters.

The registered manager had invested in the premises. They had bought new carpets and erected new fencing.

Safety measures to keep the environment safe were not always followed. A laundry door was left open and unsupervised for long periods. A small room which housed a boiler and immersion heater was marked as needing to be locked but the key was left in the lock.

The registered manager was not clear on what environmental checks needed to be carried out. An electrical report was marked as unsatisfactory. The necessary actions had not been completed to make the service’s electrical circuits safe. The registered manager was unaware a Legionella certificate was due to expire at the end of the month. We brought these points to their attention and they took action to address these areas.

Staff were not effectively deployed to ensure people were well supported. On day 1 of the inspection people had to wait to be supported with their meals. One member of staff was based in the main lounge where 16 people were eating, while the remaining 2 members of staff supported individuals in their rooms. One person wanted to leave the lounge and return to their room. We heard the member of staff say, “I can’t feed anyone, [resident name] won’t sit down, everyone’s starving.” A relative commented; “I don’t want to run anyone down, they do their best but they are run ragged.”

We observed one person was often left for long periods without support in an isolated area of the service. Staff did not have time to spend with them and they had nothing to occupy themselves with. Staff told us they were sometimes short staffed because of unexpected absences. Agency staff were had not always been used to address the shortages. Following the assessment the registered manager told us they would ensure agency staff would be used when needed.

During the lunch period on the first on-site visit staff were not deployed safely. 15 people were left without support for several minutes when staff were occupied supporting people in their rooms. Some of those left unsupervised required support and encouragement to eat their meals. This meant people were at increased risk of poor nutritional intake. Staff told us 2 people in the dining room were at risk of choking and therefore required supervising while eating.

Staffing levels were not always adequate to meet people’s needs. Four staff were required in the morning and 3 staff were required in the afternoon. Between 27th October 2024 and 14th November 2024, planned staffing levels in the morning had not been constantly achieved. There were occasions, including during our second assessment visit, when only 2 staff had been on duty in the morning. One person’s care plan stated; ‘At times may need 2 carers depending on their ability on the day.’ These staffing levels meant there was an increased risk of service users’ needs not being met. DBS checks and references were checked before new staff started work. However, not all staff had photo ID and right to work information on file. Not all staff were up to date with training identified as necessary for the service. Only one member of staff had completed moving and handling training. One person appeared on the rota but there was no record of them completing any training. Following the assessment the registered manager told us face to face moving and handling training had been booked with an external agency.

People and relatives did not raise any concerns about the cleanliness of the service.

Staff were employed to keep the service clean. We spoke with a member of the domestic staff team who told us they had cleaning schedules to follow to help ensure bedrooms and communal areas were kept clean.

We found areas of the service where improvements were needed to prevent the risk of cross contamination. Flooring in a shower room was cracked making it difficult to keep clean. Toilet rolls were kept on an open shelf and a cloth towel was available for use. One bin in an upstairs bathroom was nearly full, the bin lid was broken causing a risk of cross infection. Washing was hung over radiators to dry.

There were insufficient systems and processes to ensure people, visitors and those employed within the service were fully protected against infection control risks. There were no infection control audits completed that would identify any areas of risk or staff practice that could be improved to mitigate potential risk.

We noted there had been a series of medicine errors. It was not always clear that staff had their competency to administer medicines reassessed following errors. This was not in line with the organisational policy.

Staff responsible for administering medication were required to complete training and 6 competency observations prior to administering independently. The member of staff administering medicines on the first visit of our assessment had only completed 5 competency observations.

People’s medicines were stored safely in an office. The temperature of the room and a fridge were monitored. Protocols were in place for medicines to be given ‘when required.’ However, records to show when people had received pain relief were not consistent. One person’s MAR chart indicated they had received pain relief in the morning and afternoon on 11 and 12 Nov. Information to evidence at what time they had had it and whether it had been effective was only recorded for the morning. Although the medicine was prescribed to be given when required the records indicated they were having it routinely. This had not been highlighted to the GP for review.