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Inspection Summary

Overall summary & rating


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.


Inspection areas



Updated 8 May 2019

The service was not safe.

Risks to people’s health, safety and welfare were not always mitigated. One person had been exposed to harm.

Medicines were not always managed safely. People could not be assured they would receive their medicines as prescribed.

The provider had failed to obtain a disclosure and barring check for staff identified as requiring one at the previous inspection. This meant people could not be assured staff were suitable to work in a care environment.

People were exposed to risks from the poorly maintained environment and from limited handwashing facilities.

Staff support was not deployed in a flexible way that ensured people’s needs could be met at their preferred time, or to ensure people received supervision to maintain their safety.

Staff understood how to report any concerns about people's welfare. People felt safe.



Updated 8 May 2019

The service was not effective.

Staff did not have the training required to enable them to meet people's needs and keep them safe.

People were not always referred promptly to external healthcare services and their advice was not always followed.

People's rights under the Mental Capacity Act 2005 were being respected. The home had commenced capacity assessments and recorded best interest decisions.

People enjoyed the food. However, systems were not in place to ensure people received enough to eat and drink to maintain their health.



Updated 8 May 2019

The service was not caring.

People told us the staff were friendly and caring and we saw this in some of our observations. However, people’s privacy and dignity was not always respected.

People’s independence was promoted. However, those people at risk of self-neglect were not supported in way that ensured their needs were met.

Staff enjoyed working at the home and spoke about people affectionately.



Updated 8 May 2019

The service was not responsive.

People could not be assured their care needs were fully understood and would be met. Care records were not always accurate and did not provide staff with the guidance they required to support people with complex care needs.

Activities were limited and there was little to interest or occupy people.

Complaints and the actions required to investigate and resolve these were not recorded.



Updated 8 May 2019

The service was not well-led

The provider had failed to provide an action plan to CQC after the previous inspection and had not notified CQC of significant events they are obliged by law to do so.

The provider had failed to display the home rating.

The provider did not have effective systems and processes in place to assess, monitor and improve the service or assess, monitor and mitigate risk.

The provider and registered manager confirmed their commitment to making the necessary improvements.