Archived: Ocean View Care Home

Updated 8 May 2019

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 23, 25 and 30 April 2018. The first and third days of the inspection were unannounced. Two adult social care inspectors and an expert by experience with experience of services for older people living with dementia undertook the inspection on the first day. One adult social care inspector continued with the inspection of the second and third days. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Before the inspection we reviewed the information we held about the home. This included looking at information we had received about the service and any statutory notifications we had received from the home. A notification is information about important events which the service is required to tell us about by law. Prior to this inspection the home had been placed into “whole home” safeguarding process by Torbay and South Devon NHS Foundation Trust (the Trust). This meant the Trust had received information that people were at risk of harm and they were carrying out their own investigation. They shared this information with us and the inspection gave consideration to these concerns.

During the inspection we spent time in the communal areas of the home to observe how staff supported and responded to people. The majority of people at Ocean View were living with dementia or had mental health needs. We spent time carrying out a short observational framework for inspection (SOFI) observation. SOFI is a specific way of observing care to help us understand the experiences of people who could not communicate verbally with us in any detail about their care. We spoke with the provider, registered manager, four care staff, nine people and three relatives.

We looked at a number of records relating to people’s care and the running of the home. These included three people’s care and support plans, two staff personal files and records relating to staff training, medication administration and the quality monitoring of the home.

Updated 8 May 2019

Ocean View Care Home (known as Ocean View) provides accommodation and personal care for a maximum of 25 people. People who live at Ocean View have dementia or mental health needs. Some people also have physical disabilities. The home does not provide nursing care. People who live at the home nursing and healthcare through the local community health teams. Accommodation is provided over two floors with a passenger lift providing access to the first floor. However, there are a number of rooms unsuitable for people with impaired mobility as they are accessed by stairs. At the time of the inspection, 17 people were living at the home.

Ocean View 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.

The home had a registered manager. 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.

This inspection was unannounced and took place on 23, 25 and 30 April 2018.

The home had previously been inspected in November 2016 where it was rated Requires Improvement. At that time we identified three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to how the home managed people’s medicines, the safety the environment, the safety of the staff recruitment processes and how the home monitored the quality of the service provided to people.

Following the last inspection, we asked the provider to complete an action plan to tell us what they would do to improve the key questions of safe and well-led to good. The provider sent us an action plan in relation to the actions necessary to meet the fire safety requirements but not one for the other areas for improvement we identified.

At this inspection in April 2018, we found people could not be assured they would receive safe care and treatment. We identified a number of issues in relation to the quality and safety of the support provided. These included issues around medicines administration, mitigating risks, care planning, staff training, opportunities for engagement, as well as the management of the home. Further improvements were necessary to the environment in relation to cleanliness and its suitability for people living with dementia, as well as safety issues such as trip hazards and limited handwashing facilities.

Prior to this inspection the home had been placed into “whole home” safeguarding process by Torbay and South Devon NHS Trust (the Trust). This meant the Trust had received information that people were at risk of harm and they were carrying out their own investigation and taking action to protect people where necessary.

Risks to people’s health and safety were not being managed well. Risk assessments and care plans did not always provide staff with sufficient information to guide them in their actions to protect people. Where guidance was provided this was not always being followed. For example, people requiring assistance from staff to manage their pressure area care and continence needs were not receiving an appropriate level of support. We found one person had been experiences harm and we made a referral to the Trust’s safeguarding team in relation to their care.

Some people’s medicines were not managed safely. While most people received these safely, we observed some unsafe practice. One person was not offered their medicines in a way that meant they were less likely to refuse them and we found unused medicines stored in open and unnamed pots in the medicine trolley. This meant people were at risk of not receiving their medicines as prescribed.

Some people had a high risk of falls. These people did not have an assessment or a management plan in place to mitigate these risks. The home’s accident records did not accurately reflect the number of falls one person had sustained. People’s risk of falling was increased due to the poorly maintained carpets. The join in the carpet in the lounge room and in a person’s bedroom, were coming apart causing a potential trip hazard.

The home was found to be unclean and, in places, offensive smelling. There were limited handwashing facilities in some bathroom and toilets. Some sinks did not have a hot water supply fitted and one where there was no sink, did not have hand-cleansing gel. The provider told us they had a refurbishment plan for the home. However, at the time of the inspection we found furniture and carpeting were unclean and some was in a poor state of repair.

The environment was not suited to the needs of people living with dementia. There was no signage around the home to help people orientate themselves and to find the toilets or the communal areas. There were no pictures on the walls and no items of interest for people to engage with or which could be used to stimulate conversation. People’s bedroom doors were indistinguishable from each other. The locks used on people’s bedrooms doors were not suitable for people with impaired dexterity or for those people who might not have the cognitive ability to open a lock and a door handle at the same time.

At the previous inspection in November 2016, we identified the home had failed to obtain disclosure and barring checks (police checks) for two members of staff. At this inspection, we found that although the home had undertaken the necessary pre-employment checks for a newly appointed member of staff, the home had failed to obtain a check for the staff identified at the previous inspection.

People were unable to tell us whether there were sufficient staff on duty to meet their needs. The registered manager and staff said there were sufficient staff available. However, during our observations, we saw staff only attend to people when providing them with support to eat and drink. Some people had not received support with their personal care. At times people were unsupervised in the communal areas, including those people who were at a high risk of falls.

Those people who were able to share their views with us said they felt safe at Ocean View. Staff had received training in safeguarding people from abuse as well as in the Mental Capacity Act 2005 (MCA). However, it was not clear that staff were always putting their learning into practice. Staff were not being supported to recognise the environment within which people were living was not respectful and did not meet people’s emotional and psychological needs. Staff spoke about people with affection and friendliness. However, people’s dignity and privacy were not always respected by the staff, registered manager and provider. We observed people sitting in their underwear and other people in an unkempt state and we heard derogatory remarks made about people.

We also observed good practice from staff and saw them to be friendly and caring when engaging with people individually. It was clear staff knew people well when engaging with them in conversation. People were seen to enjoy staffs’ company and those people who had limited verbal communication were seen to make eye contact with them and smile. Staff told us how much they enjoyed working at the home. One member of staff said they thought of the people living in the home as “family” and another said people were “loved” by the staff.

Staff told us they received regular supervision and had the training they needed. However, from our observations and from reviewing care records and those relate to staff training, we identified staff required further training to support people’s physical and mental health needs. People’s pressure area care, continence management, as well as their needs related to living with dementia and mental health conditions were not being appropriate or safely supported.

There were few opportunities for people to engage in leisure or social activities to provide stimulation and engagement. We observed people spending long periods of time without any staff involvement or engagement other than when they were being supported to eat and drink. When people were engaged in an activity or when receiving staff attention, it was clear they enjoyed this.

People told us they enjoyed the food provided by the home. People were offered a choice of meals and staff were aware of their preferences. Those people who required their food to be modified, such as pureed due to swallowing difficulties, received appropriate support. However, for those people at risk of malnutrition and dehydration, monitoring of their food and fluid intake was not effective in ensuring they received enough to eat and drink.

At the previous inspection in November 2016, we found the home’s quality assurance and monitoring systems were not effective and had failed to identify the concerns identified at that inspection. At this inspection, in April 2018, we found improvement had not been made and the home did not have effective systems in place to assess, monitor and improve the quality of the service provided. The registered manager told us feedback from people was sought, but there was no record of this.

The provider and registered manager told us they were committed to making improvements and recognised the home had not been providing the level of care and support it should. A staff meeting had been arranged for the third day of the inspection to discuss the changes needed to improve people’s experiences and to ensure they received the care and support they required.

We found shortfalls in the care and service provided to people. We identified 12 breaches in regulations. The overall rating for this service is 'Inadequate' and the service is th