Ocean Hill Lodge Residential Care Home

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Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. This is the first assessment for this newly registered service. We found evidence contributing to 2 breaches of the regulations; governance and notifying CQC of incidents. There was a lack of effective leadership and oversight, audits had failed to identify the concerns found at the assessment. The provider had not notified the Commission of significant events as required

This service scored 32 (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 recent changes to the management of the service. Staff felt unsupported and there was a lack of clear direction. Comments included; “[Name of senior carer] is our only leader at the moment. It’s a real worry” and “I’m worried about being without a manager. [Registered manager] is constantly trying to get us to help with care plans.”

We observed some examples of a poor culture, the registered manager was not addressing these areas. For example, staff tended to congregate around a dining table and take breaks together despite the low staff numbers. During the on-site assessment an agency worker, who had not worked at the service previously, arrived to support the staff team. There was no agency induction process completed.

There was a lack of clear leadership. Staff were unclear about roles and responsibilities. One said; “We would have gone to [ex registered manager name]. I don’t know now.” Some staff told us they were being asked to complete tasks they were not confident doing. One commented; “There’s no-one in control of the home and that makes me nervous. I’m being asked to do jobs I don’t feel confident doing.” The registered manager was staying in the locality to oversee the service. However, they were unable to provide information requested due to their lack of knowledge about the services systems.

One of the two registered managers had recently left the service and cancelled their registration. The remaining registered manager was not based locally and had limited working knowledge of the service. They were not familiar with people’s specific needs or the systems and processes used to oversee the running of the service. Following our on-site assessment an interim manager was appointed to oversee and drive improvements.

Staff told us they did not feel they were being kept informed about changes in the service. Following advice from the local authority quality assurance team the registered manager had held a staff meeting to try and reassure staff. However, not all staff had been able to attend. Those that had reported the meeting had been brief with no opportunities to ask questions. Staff told us they did not feel valued. One commented, “We just feel we’re being pooped on really.”

There were no processes for gathering staff views. Resident and relative meetings were held. However, a relative told us issues raised in meetings were not addressed and resolved.

Staff told us they were being asked to work longer hours than contracted and this was impacting on their personal lives. Some staff told us they were considering leaving the service due to the pressures of working long hours and being asked to complete tasks they were not confident doing. Staff reported changes had been made to their contracts without consultation and that agreed payments for completing training had not been made.

There was an Equality and Diversity policy. No staff said they were treated differently due to their diverse needs. However, discrepancies in the accuracy of staff pay had caused unnecessary stress due to possible unnecessary impacts on benefits payments.

Roles and responsibilities were not clearly defined. At the time of the on-site visits the deputy manager was on leave. The registered manager was very reliant on more experienced staff to address shortcomings such as developing care plans and ordering medication. Other carers told us they had been asked to complete senior carer roles. One commented, “[Registered manager] is constantly trying to get us to help with care plans and Personal Emergency Evacuation Plans, it’s tough.”

Some audits and checks were not taking place. This was partly due to the change of management arrangements. Some issues were more longstanding. For example, the failure to recheck staff competencies after any medication error and poor processes for protecting people from the risk of financial abuse. The service had failed to notify the Commission of relevant events in line with legislation.

One person was able to go out independently. Staff encouraged them to maintain their links outside of the service.

Staff told us they supported people when they needed to attend hospital appointments or access other services.

A professional told us how the service had tried to support someone to continue using a mobility scooter. They explained it had been difficult to find a service willing to do this and the opportunity had been important to the person.

Information about people was not always up to date or accurate. This meant information shared with other agencies was not reliable.

The registered manager acknowledged there were many areas for improvement. Following our on-site assessment visits an interim manager was recruited as well as a permanent manager, a senior and additional care staff.

The lack of effective recording and auditing systems meant areas for improvement had not been identified. Although staff were motivated to provide good care, they had not had the relevant training or leadership necessary to provide effective care. Staff meetings were not scheduled regularly and there were no systems to enable information and learning to be shared. Night staff had not had a staff meeting in 2024. The most recent staff meeting for care staff had been in July 2024. Following the assessment visit a staff meeting was arranged. However, staff told us this had been rushed and they had not had an opportunity to share their views. There was no evidence the registered manager kept up to date with developments in the health and social care sector. They were not part of any forum and lacked experience of managing services.