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Oaktree Care Home Requires improvement

Reports


Inspection carried out on 5 March 2019

During a routine inspection

About the service: Oaktree Care Home is registered to provide personal and nursing care for up to 78 people. The service is divided over two separate floors. The ground floor, called Bluebell is for those who require nursing care and the upper floor is dedicated to those people living with dementia and has two units called Primrose and Snowdrop. Snowdrop, provides support to people living with dementia but do not need nursing care. There were 59 people living at Oaktree Care Home when we inspected.

People’s experience of using this service:

Since our last inspection, improvements had been made to ensure complaints were dealt with promptly with feedback given to the complainant. It was evident people felt their concerns were listened too and acted upon swiftly.

As seen at the last inspection, there was a heavy reliance on agency staff whilst the registered manager was recruiting to the vacant posts. This was having an impact on the delivery of care. People were not receiving the care when they needed or wanted it. This was in part due to the high agency usage and many of the people needing two staff to support them, which was not taken into account when calculating the staff on the nursing unit.

Staff were not being fully supported thorough regular supervisions and annual appraisals. Whilst staff had received training on a variety of topics, overall the home had not achieved the provider’s own internal compliance figures. Staff had not received training relevant to the needs of people they were supporting, such as diabetes.

Care was planned and delivered but not always in a person centred way in line with people’s preferences. This was being addressed by the registered manager, who was reviewing practice around the times when people were supported to get up for the day.

People felt safe living at Oaktree and risks to people were minimized through risk assessments. There were plans in place for unforeseeable emergencies. However, some people felt safer when supported by regular and familiar staff.

We have recommended the service review their menu planning to ensure it includes variety and all the food groups. There was a vacant chef post which was impacting on the quality of the food provision. Agency catering staff were covering the vacant hours.

People were consulted about their care and support needs and involved in decisions about their care. Staff had a good understanding of the legislation to protect people where they lacked capacity involving family and other professionals. People and their relatives told us the staff were kind and caring. Feedback was complimentary about the regular and familiar staff.

There was an ongoing decoration programme in place. The home was clean and free from odour.

There were systems in place to monitor the quality of the care and support. However, there were no improvement plans in place to ensure ongoing compliance from findings of the provider visits.

Rating at last inspection: Requires Improvement. (Report published June 2018).

Why we inspected: This was a planned inspection based on the rating at the last inspection. We saw improvements had been made since our last inspection. Our findings at this inspection have meant the rating remained Requires Improvement. This is the second time this service has been rated Requires Improvement.

Follow up: We will meet with the provider following this report being published to discuss how they will make changes to ensure the provider improves the rating of the service to at least Good. We will revisit the service in the future to check if improvements had been made.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Inspection carried out on 25 April 2018

During an inspection to make sure that the improvements required had been made

This was a focused inspection because we had received some concerns about the service from relatives. This was about the response from the service to complaints, electrical equipment and pressure mattresses and concerns about care delivery. There has also been an increase in notifications of incidents that affect the well-being of a people in the last three weeks prior to the inspection around falls and unexplained bruising. We focused on these areas to check whether the service was safe, responsive to people needs and whether the service was well led.

The inspection was completed on the 25 April 2018 and was unannounced. The service was last inspected in February 2017 and was rated as good in all areas with no breaches in regulation.

Oaktree Care Home 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.

Oaktree Care Home is registered to provide personal and nursing care for up to 78 people. The service is divided over two separate floors. The ground floor was called Bluebell is for those who require nursing care and the upper floor is dedicated to those people living with dementia and is called Primrose. Since the last inspection, a further unit had been opened on the first floor called Snowdrop, which provided support to people living with dementia but did not need nursing care. There were 59 people living at Oaktree Care Home when we inspected.

There was a registered manager in post. A registered manager is a person who has registered with the CQC 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.’

From our inspection, it was evident that not everyone felt their concerns were listened too and acted upon swiftly. This was because people and their relatives were not receiving an acknowledgement or a prompt response on what action had been taken to address their concerns. Some concerns were taking longer time to investigate than the provider’s complaint policy and not all concerns/complaints were recorded on the central record. This meant the provider and registered manager were unable to look for any themes. We have asked the provider and registered manager to make improvements in this area.

Concerns were raised with us prior to this inspection on how some of the equipment was maintained such as electrical appliances and pressure relieving mattresses. We saw that checks were completed on the electrical appliances annually. However, it was evident that the external contractor had missed items in people’s bedrooms and two bedrooms had not been checked. The provider has reviewed their contract with this company and new contractor has been commissioned. This was because they could not be assured all items had been checked. Assurances were provided that this would be completed the day after the inspection.

Staff completed regular checks on the mattresses with records maintained. Where the family had raised concerns, this had been addressed with actions being taken to reduce further risk. Where staff were checking floor and chair sensor mats the records could potentially indicate there was a gap in recording because there was no record to indicate that they had changed position such as moving to another area of the home or had retired to bed. Assurances were given by the unit manager and the registered manager that this would be addressed. The registered manager was aware that there were some shortfalls in recording and was addressing this through team meetings and via one to one with staff members.

People told us the staff were usually responsive to their requests for assistance when using their call bell. One person told us they h

Inspection carried out on 22 February 2017

During a routine inspection

This inspection took place on 22 and 24 February 2017. We carried out this inspection because we found two breaches of regulation at the last inspection in February 2016. The provider sent us an action plan which we reviewed during this inspection.

Oaktree Care Home is registered to provide personal and nursing care for up to 78 people. The service is divided over two separate floors. The ground floor was called Bluebell is for those who require nursing care and the upper floor is dedicated to those people living with dementia and is called Primrose. There were 47 people living at Oaktree Care Home when we inspected.

There was a registered manager in post. A registered manager is a person who has registered with the CQC 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.’

We found at our last inspection in February 2016 there were some areas the service had to improve to ensure people were safe in respect of the management of medicines and the recording of complaints. Improvements in these areas were noted. The registered persons had taken appropriate action to address these areas.

It was evident that since our last inspection the service had sustained and continued to make improvements where required. Feedback from people, their relatives and visiting health professionals was positive about the care and support that was in place. The service was well led with good leadership from the registered manager and the unit managers in ensuring these improvements continued. Staff told us they were working as a team to support people in an individualised way. Feedback from visiting health and social care professionals provided us with evidence that the staff understood and knew the people they were supporting well. This was echoed by people who used the service and their relatives.

People were safe because where their care needs had changed or an incident had occurred, appropriate action had been taken. Where incidents were identified as potential abuse; staff were reporting and an investigation was completed. This included reporting incidents and accidents to the local safeguarding team and submitting notifications to the CQC. Notifications tell us about significant events that happen in the service. We use this information to monitor the service and to check how events have been handled. People’s rights were protected and where restrictions were in place this was done with the appropriate authorisation involving other professionals. This was kept under review.

Systems were in place to ensure people were safe including risk management, checks on the environment and safe recruitment processes.

People were receiving care that was responsive and effective. Care plans were in place that described how the person would like to be supported. The care plans provided staff with information to support the person effectively. People’s health care needs were being met. Other health and social professionals were involved in the care of the people living at Oaktree. Referrals were made in a timely manner for people where required.

People’s nutritional needs were being met. Where there were risks to people there were clear plan of care in place, additional monitoring and good communication between the care and catering staff.

Staff were caring and supportive and demonstrated a good understanding of their roles in supporting people. Staff had received training and support that was relevant to their roles. This had included all staff at all levels in the working towards an accredited training programme for supporting people with dementia. Systems were in place to ensure open communication including team meetings and daily handovers. A handover is where important information is shared between the staff during shift changeovers. This ensur

Inspection carried out on 17 February 2016

During a routine inspection

This inspection took place on 17 and 18 February 2016. We carried out this inspection because we found a number of breaches of regulation during the last inspection in September 2015. The provider sent us an action plan telling us they would be compliant by December 2015.

Oaktree Care Home is registered to provide personal and nursing care for up to 78 people. The service is divided over two separate floors. The ground floor called Bluebell is for those who require nursing care and the upper floor is dedicated to those people living with dementia and is called Primrose.

There was a manager in post. The manager commenced in post in October 2015. They had not submitted an application to become the registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC 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.’

After the last inspection we took enforcement action against the provider. This was to prevent them considering any new admissions on Primrose without prior written authorisation from the Commission. There had been no admissions to Primrose since the last inspection. The regional manager, the manager and the unit manager said they felt that they were now satisfied people were receiving safe and appropriate care and would like to start to admit people to Primrose using a phased approach. The provider must contact the Commission prior to any new admissions.

There had been significant improvements since our last inspection in respect of how people were being treated, how staff were responding to their care needs ensuring they had access to appropriate professionals. There was a clear and committed management team working across all areas of the home. Staff confirmed since the last inspection there had been improvements on Primrose and they felt there were a more cohesive team which was being led by the unit manager.

There were some areas that required further improvement including the management of complaints and ensuring people received their medicines safely. This was because there was a lack of guidance for staff about ‘when required’ medicines such as pain relief and medicines to reduce anxiety. Improvements were required in respect of stock control where medicines were not given from pre-packaged ‘blister’ packs. This would mean there would be a system to pick up quickly if medicines had not been administered at the correct time.

People were supported by sufficient staff. However, it was recognised by the provider, the manager, staff, relatives and people who use the service that there was a high usage of agency staff. This was having an impact on the delivery of care because the agency staff were not always responsive to people’s changing needs. Health care professionals had seen some improvement but remained concerned that the agency staff did not always know the person well enough. Steps were being taken by the provider to recruit to the vacant staff posts.

People were safe because where their care needs had changed or an incident had occurred, appropriate action had been taken. Where incidents were identified as potential abuse; staff were reporting and an investigation was completed. This included reporting incidents and accidents to the local safeguarding team and submitting notifications to the CQC. Notifications tell us about significant events that happen in the service. We use this information to monitor the service and to check how events have been handled.

People were receiving care that was responsive and effective. This had significantly improved since our last inspection. Care plans were in place that described how the person would like to be supported. The care plans provided staff with information to support the person effectively. Other he

Inspection carried out on 8,9 and 29 September 2015

During an inspection to make sure that the improvements required had been made

This inspection took place on 8, 9 and 29 September 2015. We carried out this inspection because we had a number of concerns shared with us. These concerns came from a range of different sources including, relatives, health and social care professionals who had visited the service, South Gloucestershire County Council and a whistle blower. A whistle blower is a member of staff who works for the service and had reported concerns but not been listened to. These concerns were about the care and support people were receiving on the dementia suite. This was a focussed inspection looking at only the Dementia suite, in line with our procedures we have not changed the overall rating of this location.

We visited the service on 24, 26 and 27 February 2015. At that time, we rated the service as inadequate and identified a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. We visited the service again on 8 and 9 June 2015.

We found some improvements had been made and rated the service as requires improvement. However, we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Oaktree Care Home is registered to provide personal and nursing care for up to 78 people. The service is divided over two separate floors. The ground floor is for those who require nursing care and the upper floor is dedicated to those people living with dementia. At the time of our inspection there were 24 people living on the dementia suite.

There was a registered manager in post. 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.’

People were not always supported by sufficient staff. There was only one permanent qualified nurse employed to work on the dementia suite. The shortfall was being covered by agency and bank nurses who did not always know the people they were caring for. This resulted in communication not always being effective with health and social care professionals and had contributed to inconsistent recording in care documentation.

People were not always safe because where their care needs had changed or an incident had occurred, appropriate action had not always been taken. Incidents were not identified as potential abuse; they were not reported or investigated. This included reporting incidents and accidents to the local safeguarding team and submitting notifications to the Care Quality Commission (CQC).

People could not always be assured they were receiving their medicines as they wished. Staff were not always signing for creams and ointments so it was not clear if people were receiving these as required. There was a surplus supply of medicines that was being returned to the pharmacy. This could be an indicator that people were not receiving their medicines as prescribed by their GP. Medicines were not being stored safely in respect of controlled medicines.

Care records were not accurate or detailed enough and could potentially mean that people were not receiving the care and support they required. People did not always receive medical support and interventions in a timely way to ensure their health and well-being.

People were not always supported to make their own choices and where people had made advanced decisions these were not always taken into account. People’s care was not personalised and did not reflect their individual needs and preferences.

There was a lack of meaningful activities for people on the dementia suite which was leading to some people feeling bored. Most people were disengaged and spent long periods of time with little or no stimulation.

Some staff were caring but this was not always consistent. Our observations throughout our visit, discussions with people using the service, their families and staff and examination of records, all gave the impression the service was task orientated.

The provider did not have effective systems in place to assess, monitor and improve the quality of care. Poor care was not being identified and rectified by the provider.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

Inspection carried out on 8 and 9 June 2015

During a routine inspection

This inspection took place on 8 and 9 June 2015. We had been due to follow up the breaches of legal requirements that we found in February 2015, however we had a number of concerns raised with us because of hospital admissions and ‘whistle blower’ information. A whistle blower is a member of staff who works for the service and had reported concerns but not been listened to. They had therefore contacted CQC and told us about their concerns.

Oaktree Care Home is registered to provide personal and nursing care for up to 78 people. The service is divided over two separate floors. The ground floor is for those who require nursing care and the upper floor is dedicated to those people living with dementia. At the time of our inspection there were 27 people living on the upper floor and 34 on the nursing floor.

There was a registered manager in post. 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.

The providers own recruitment policy and procedure had not been followed and this meant that people could be at risk of being looked after by unsuitable staff.

Care records were not accurate or detailed enough and could potentially mean that people would not receive the care and support they specifically needed. Communication between staff handing over to the next shift needs to be improved to ensure the ongoing healthcare needs of people are met appropriately.

All staff received safeguarding adults training. The staff team were knowledgeable about safeguarding issues, and had taken the appropriate actions when concerns were raised. They had reported events promptly to the local authority and CQC. At the time of the inspection there were a number of safeguarding investigations still ongoing. The appropriate steps were in place to protect people from being harmed.

A range of risk assessments were completed for each person and appropriate management plans were in place. The premises were well maintained and all maintenance checks were completed.

The registered manager monitored the staffing levels on both units and based the staffing numbers on the care and support needs of each person in residence. All staff felt that the staffing numbers were now appropriate, they were able to meet people’s needs and their safety was not put at risk.

All staff completed a programme of essential training to enable them to carry out their roles and responsibilities. New staff completed an induction training programme and there was a programme of refresher training for the rest of the staff. Care staff were encouraged to complete nationally recognised qualifications in health and social care.

People were supported to make their own choices and decisions where possible. Where people lacked the capacity to make decisions, assessments were recorded of best interest decisions. We found the home to be meeting the requirements of the Deprivation of Liberty Safeguards.

People were provided with sufficient food and drink. Their specific dietary requirements were catered for and extra food was provided for those people who did not eat well. There were measures in place to reduce or eliminate the risk of malnutrition or dehydration, but improvements were needed with the monitoring of records. Arrangements were made for people to see their GP and other healthcare professionals when they needed to.

The staff team had good friendly relationships with the people they were looking after. People were able to participate in a range of different activities and external entertainers visited the home. The service only had one activity co-ordinator, one was currently not available to work and a third member had recently been recruited.

There was a staffing structure in place and the staff teams in both units were led by a unit manager. Regular staff meetings were held in order to keep all staff up to date with changes and developments in the service.

The registered manager had a regular programme of audits to complete which ensured that the quality and safety of the service was checked. These checks were completed on a daily, weekly or monthly basis.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

Inspection carried out on 24, 26 and 27 February 2015

During a routine inspection

This inspection took place on 24, 26, 27 February 2015 and was unannounced. At the previous inspection of 10 and 11 September 2014 we found there were two breaches of legal requirements. These were related to staffing levels and care documentation.

Oaktree Care Home is registered to provide personal care and nursing care for up to 78 people. The service was divided over two separate floors. The ground floor was for those who required nursing care and the upper floor was dedicated to those people living with dementia. On the visit of 24 February there were 27 people living on the upper floor and 35 on the nursing floor.

There was not a registered manager in post. 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. A manager had been appointed in December 2014 and they had applied to register with the Commission.

It was evident throughout the inspection there was a significant divide between the safety and quality of services provided on the nursing floor and the upper floor.

There had been a reduction in staffing levels on the upper floor between 2 and 24 February. On 24 February we found people’s safety had been put at risk which had resulted in accidents, incidents and injury. Two people had been assessed as requiring one to one support due to an increase in falls but the staffing levels were unable to support this. People were not receiving personalised care and their dignity and respect had been neglected. Routines had been compromised including mealtimes where people who required assistance were left unsupported with food and drink. Staff were unable to effectively support two people whose health had significantly deteriorated that day. All staff working on the upper floor were “tired, frustrated and demoralised”.

The manager contacted the area manager on the evening of 24 February 2015 who agreed to increase staffing to the original levels prior to 2 February 2015. On our return visit of 26 February things had improved. The number of people had decreased from 27 to 25. It was a quieter day and things were calmer and more settled. There were no emergencies or significant events during the day. Staff morale was more positive and they had recommenced their previous routines and ways of working. In addition to this the local authority were urgently reviewing funding for the two people who were prone to falling so they could have one to one support from additional staff members.

Because the staffing levels had increased and the risks had reduced we continued the visit of 26 February gathering evidence about other areas we needed to look at. People living on the nursing floor were safe and there were enough staff to meet people's needs. They confirmed care and support was personalised. Choice and personal preferences were encouraged and supported by staff. People on the nursing floor told us they were listened to. Mealtimes were “pleasant and enjoyable” and people had sufficient amounts of food and drinks. People on the nursing floor told us they were “happy” with the care they received and had “no complaints”. Staff were equally “happy” and “enjoyed” their work.

Staff were knowledgeable in safeguarding procedures and knew how to identify and report any abuse. Suitable recruitment procedures ensured staff were safe to work in the service. The service had been closely monitored through an external multi-agency approach over the last year due to repeated ongoing safeguarding’s. This was led by the local authority safeguarding team. Other participants included, the Care Quality Commission, GP’s, community nurses, social workers and local authority commissioners. The commissioners were responsible for funding people who lived in the service.

People living with dementia on the upper floor were not always receiving their medicines at the prescribed time. Nurses on both floors were not following medicine policies and procedures.

Staff received training so they had the knowledge and skills they needed to carry out their roles effectively. They felt supported on a day to day basis by the manager, unit managers, nurses and colleagues. Formal supervisions were underway for this year and dates for appraisals had been arranged.

People and relatives said staff were “caring and thoughtful” and there had been improvements following the previous inspection. There were positive interactions between people and staff. Staff had a good awareness of individuals' needs and treated people in a warm and sensitive manner. However we did see some poor practice on the upper floor where people’s dignity had not been respected at mealtimes and some people looked unkempt.

On our final visit of 27 February we met with the manager and area manager. We were shown email correspondence and attachments which evidenced that the manager had made an error when completing the tool that determined staffing levels. Because they had omitted to complete sections of the tool it had indicated the levels should be reduced. This meant during the period of 2 February to 24 February there were insufficient staff levels to safeguard the health, safety and welfare of people on the upper floor. However, suitable steps had been taken on 24 February to address this. The providers quality assurance procedures failed to identify that the staffing level tool had been completed incorrectly. This raised concerns about the effectiveness of the provider’s quality assurance systems.

We found seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We completed this inspection at a time when the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009 were in force. However, the regulations changed on 1 April 2015; therefore this is what we have reported on. You can see what action we told the provider to take at the back of the full version of this report.

Inspection carried out on 10, 11 September 2014

During an inspection to make sure that the improvements required had been made

The purpose of this inspection was to follow up previous enforcement action where we identified serious failings in protecting people against the risks of infection control.

Below is a summary of what we found. The summary is based on our observations during the inspection, seeking experience and views from people who used the service, their relatives, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary, please read the full report.

Is the service safe?

The service was clean and hygienic. Appropriate guidance, equipment and facilities were in place for staff so that people were safe and protected from the risks associated with cross infection.

Is it well led?

The quality monitoring systems in place had improved and were more effective in identifying where improvements were needed.

Inspection carried out on 10, 11 September 2014

During an inspection to make sure that the improvements required had been made

At the time of the inspection the home did not have a manager. The provider had redeployed an interim manager. They had been managing the home for six weeks prior to our visit. A new manager had been appointed but they had not commenced at the time of our inspection.

The purpose of this inspection was to follow up previous non-compliance where we identified serious failings in the home.

Below is a summary of what we found. The summary is based on our observations during the inspection, seeking experience and views from people who used the service, their relatives, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary, please read the full report.

Is the service safe?

People were protected from the risks of inadequate nutrition and dehydration. People were being supported at mealtimes so that they received sufficient amounts of food and drink that was provided to them.

The service was clean and hygienic. Appropriate guidance, equipment and facilities were in place for staff so that people were safe and protected from the risks associated with cross infection.

People lived in surroundings that were safe and promoted their wellbeing. Equipment provided to people was safe and properly maintained.

Additional cover was provided when there was any staff absence. We could not be satisfied that there were enough staff on duty. The staffing tool had been further developed and had taken into account the geography of the home, skill mix and dependency levels of people. However this was still in its pilot stage and under review.

Is it effective?

Improvements had been made to ensure people received appropriate care and support by using effective systems to assess, plan, implement, monitor and evaluate people's needs. People were now being involved throughout these processes. This ensured their needs were clearly identified and the support they received was meaningful and personalised.

Areas of additional training had been identified that were relevant to people's needs and to promote best practice. Training had been booked and some training had been completed.

Additional training, reviews of daily routines, new initiatives and equipment had helped ensure that people were receiving a nutritionally balanced diet and a sufficient fluid balance.

Is the service caring?

Staff treated people kindly and they were receiving care in a way that respected their dignity and independence. People were being supported at mealtimes with patience and by staff that were sensitive to their needs.

Additional training and care plan reviews had supported an individualised approach to care and independence was promoted.

The keyworker system and “resident” allocation had increased staff awareness of individuals' needs. Staff we spoke with were knowledgeable about people’s lives, their likes and dislikes. Efforts were being made to enhance this knowledge so that their life experiences remained meaningful.

Is it responsive?

Improvements had been made to ensure people were involved in making decisions about the care and support they received.

Appropriate referrals were made to health and social care professionals. There had been recent referrals to nutritional and dementia specialists. This had provided staff with appropriate guidance so that people were supported safely in order to minimise the risks and enhance people’s experience.

It was evident that the home was making every effort to respond to the failings identified at the inspection of May 2014 in order to improve the quality and safety of service provided.

Is it well led?

In the absence of a registered manager the provider had deployed an interim manager in order to address previous non-compliance and to help support consistency and leadership in the home.

The quality monitoring systems in place had improved and were more effective in identifying where improvements were needed.

New systems had been implemented. Meetings for people and their relatives supported empowerment and effective change. The interim manager had looked at ways that staff would feel valued and be able to effect positive change and equally feel supported. Their ideas and experiences were being sought through new “Heads of Department” meetings.

You can see our judgements on the front page of this report.

Inspection carried out on 14, 15, 19 May 2014

During an inspection in response to concerns

The purpose of this inspection was to find out five key questions. Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, seeking experience and views from people who used the service, their relatives, and the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service caring?

We found that staff we saw treated people kindly but people did not receive care in a way that respected their dignity and independence.

One person who lived in the home told us, “Some staff just complete tasks; they go through the motions or not as the case maybe. I think this is attributed to a lack of knowledge, education and that there is not enough staff”. One staff member told us, “I wish I could say care was individualised but we just don’t have the time. We do as much as we can but I have to admit we are only able to provide the basics”. We saw that staff were rushed throughout the day.

People’s personal care needs were not respected and their dignity was compromised, for example people had not been assisted to wash and dress as they would wish or helped to eat their meals. We saw people with food left in their laps following mealtimes; clothes were not always protected from spillages from food and drink.

People were not cared for in a home that was safe and clean, with poor hygiene standards throughout the home. The premises, décor and soft furnishings were tired and in need of replacement and repair.

Is the service responsive?

We saw that appropriate referrals were made to health and social care professionals. Staff had identified risks to people and how this would be managed. This included people that had swallowing difficulties and were at risk of choking.

People had been assessed by their GP and the speech and language therapists and staff were following the guidance so that people were supported appropriately and safely in order to minimise the risks.

Is the service safe?

People were not protected from the risks of inadequate nutrition and dehydration. This was because people were not helped at mealtimes so that they received sufficient amounts of the food and drink that was provided to them.

Because there were discrepancies around accurate recording in people’s charts staff and people using the service could not be assured that food and drink intake monitoring was effective. This meant that staff may not be aware that people were at risk of poor nutrition and hydration and take any necessary action.

The service was not clean and hygienic. Appropriate guidance, equipment and facilities were not in place. This meant that people who used the service were not safe or protected from the risks associated with cross infection.

People did not live in surroundings that were safe and promoted their wellbeing. We found that equipment provided to people was unsafe and not properly maintained.

The home had less staff on duty than the manager had determined were needed to meet people’s needs. Additional cover was not provided when there was any staff absence. Staffing levels did not take into account unforeseen circumstances or emergencies.

Relatives had expressed concerns about access to staff at weekends, they questioned the staffing levels in the home and they were concerned about how long people’s call bells rang before they were answered.

Is the service effective?

Some care plans only contained basic information and guidance about the care and support people required. They did not show that people had been involved in developing their own care plans so that the staff could provide them with personalised care.

We spoke with two relatives who were visiting two people living with dementia. They told us, “I have not been asked to be involved in care plans I don’t know what they are” and “It was mentioned at the relatives meeting in April that we could be involved in care plans but I haven’t heard anything since then”.

People were not supported to be independent at mealtimes because they were not provided with the appropriate equipment to help them to eat.

The needs of people living with dementia had not been considered with regards to their environment. There were no signs that would help people move around independently. Equipment was stored in en suites and in communal bathrooms and toilet facilities. This meant that people could not move around freely and safely.

Is the service well-led?

We found not all aspects of the service were well-led

The home did not have a registered manager, although an application to register had been made. The management arrangements did not provide strong leadership as action had not been taken to improve the care or environment in the home. We found that the quality monitoring systems in place were not effective and had not identified improvements where needed.

This included the homes environmental audit which had failed to identify the serious concerns we found during our visits regarding the quality and safety of the environment. The audits did not identify risks to people who used the service in order to keep them safe from harm.

Inspection carried out on 18 July 2013

During a routine inspection

The home is divided into two parts; upstairs provides care for people with complex needs and the downstairs which accommodates those with residential and nursing care needs. We spoke with eight people who lived in the home and their relatives. People told us that staff always asked them what they wanted and would never do anything without their permission. People agreed that staff treated them respectfully.

Staff had been employed for a number of years and it was evident that relationships with the people had been established over a period of time. Visiting relatives spoke positively about Oaktree and that they were “happy with the care that is being provided”. The staff team were knowledgeable about people’s needs and this was evident when we spoke with them.

One visitor told us they had visited the home three times before making a decision for their relative to move in. They said that on each occasion they found the home to be “the same” and felt it was the “best home in the area”. They described how supportive, helpful and friendly the staff were. They said their relative had “settled well” and that staff were ”knowledgeable about how to meet their relative’s needs”. They were very happy with the choice of home and added that other members of the family had expressed this to them.

Several visitors told us their relatives had previously used the home for short stay ‘respite’ care. They said this was the reason they had chosen to move in permanently. They expressed that they were happy with their relative’s care needs being met and spoke about the “good” communication within the home.

Inspection carried out on 5 March 2013

During an inspection to make sure that the improvements required had been made

We carried out this inspection because previously we did not follow up on arrangements where there were concerns expressed. These related to safeguarding and arrangements for the administration of medicines. In addition there were some concerns a bout staffing arrangements.

At this inspection we found the home to be compliant with the outcomes. Staff had received safeguarding training and knew about the importance of reporting suspicions of abuse. The home had continued to alert the local council to suspicions of abuse.

There were regular audits of the arrangements for administering medicines and where actions were identified these were responded to.

Recruitment of staff ensured there were sufficient numbers of workers to support people.

Inspection carried out on 3 December 2012

During an inspection to make sure that the improvements required had been made

We visited the home to follow up minor concerns we had with people's care and welfare following our visit to the home in July 2012. At that time we felt that people experienced care, treatment and support that met their needs and protected their rights. However, the provider had introduced a new care recording system and it was not fully implemented. Record keeping needed to be improved to demonstrate that people received safe and appropriate care and treatment.

During our follow up visit we looked at the care records for six people and found them to be accurate and up to date. Assessments of needs were carried out to enable care planning. There were written comments in relation to people's care needs and monthly evaluations were completed. Where necessary care plans were complemented by charts for monitoring food and fluid intake, weight and vital signs.

We had previously felt that the lunchtime dining in the dementia unit was drawn out and not the best experience for people. During this visit we saw that alternative arrangements were in place and people were engaging with each other in a more relaxed environment.

Inspection carried out on 17 July 2012

During a routine inspection

We spoke with two people who lived in the home. They told us they were happy and felt well looked after. They said staff were good and gave them the assistance they needed. They told us their relatives were made to feel welcome and they liked the variety of food. People told us staff called them by their preferred name. They both told us they would speak with a nurse if they were unhappy about anything.

We spoke with three relatives of people living in the home. One of them told us how their mother moved into the home in a very frail condition from hospital. They said their mother had gained weight, had recovered from ulcerated legs and had an improved quality of life. The home had arranged for a special chair that enabled the person to spend the day in the lounge which they liked to do. The relative said they were happy that their mother lived in the home and that staff responded to all requests. They said they would complain if they were unhappy and felt they would receive a good response.

Other relatives told us they were happy with the service provided at Oaktree House. They said they had no reason to complain but would be listened to if they did.

A visitor who came to the home to see their ex-neighbours said they always found them well dressed and had never seen anything they were not happy about.

The four staff we spoke with were happy in their work. They had worked at the home for varying lengths of time and had different roles. They all said they felt supported by the management of the home. One of the staff spoke about the good team working in the home and the pleasant atmosphere.

We met a visiting medical professional. They told us they had been visiting the home for a number of years and had good relationships with staff who were friendly. They said they usually got all of the information they needed and staff followed instructions well.

Inspection carried out on 14, 21 November 2011

During an inspection in response to concerns

We reviewed the service as a result of concerns which had been raised with South Gloucestershire Council through the safeguarding team. The concerns raised focused on the dementia care floor of the home.

We saw evidence of good team work and a supportive environment. The staff that we spoke with all said that they had not experienced any bullying within their work environment and that they felt supported by the current peripatetic manager.

There were practical signs of minimal staffing levels on duty both during the day and at night. We observed some gaps in record keeping and staff told us that they had been short staffed on the day of our visit. They told us they had not really had time to take breaks. We saw that although there were enough staff rostered on to work each shift within the home as a whole the numbers of staff rostered on each floor did not reflect the staffing ratios expected for the number of residents within the home.

Staff we spoke with demonstrated a good understanding of the people's needs but appeared under pressure to fulfil care tasks due to minimal staffing levels. Despite minimal staffing levels we observed both day and night staff treating people with dignity and respect. We saw staff talking to people in a calm and clear manner and going at people’s pace.

No-one living in the home was able to look after their own medicines at the time of our inspection. All medicines are looked after and given by staff. We saw staff giving people their morning medicines in a safe and respectful way.

We saw that one person had not wanted to take their medicines when they were first offered. The nurse returned later to offer them again. When they were again not wanted nursing staff safely disposed of the medicines. We saw another person was not awake at the time of the medicine round and that although staff tried to wake the person they were not able to take their medicines at that time. The nurse returned later to administer their medicines.

We observed that people are given medicines in a caring and sensitive way. Medicines were put into a plastic medicine cup and people were supported to take their medicines in a manner that they wished. We saw that nursing staff put each tablet (or capsule) onto a spoon in order that people could take their medicines one at a time.

Inspection carried out on 21 September 2011

During an inspection in response to concerns

We spoke with five people who use the service they told us they enjoy living in the home and that they receive the help and care they need. People said "the carers are nice", "it's a pleasant place to live", "I get the help that I need", "it's very nice and people are very kind", "the food is nice and I get a choice of things" and "they look after me well".

The people we spoke with were unaware that they had a care plan in place which reflected their needs.

People told us that staff come quickly when they press their call bell. One person told us "you can always get hold of somebody".

We asked people about their involvement in activities within the home. One person said "I'm not involved in activities in the home, I don't want to be". They went on to say that the activities coordinators come and see them even though they do not want to be involved in the activities. This resident was aware of the activities occurring within the home because they had been given a newsletter which detailed the activities occurring that month. Other people were aware of the activities going on in the home too and told us that they had been on trips out occasionally, and had been involved in the entertainment within the home. One person told us they had not been involved in any activities which were just for them within the home, although their son takes them out of the home regularly. People told us that they were not bored in the home.

People told us they were unaware that they had a care plan in place and were not involved in the planning of their care. One person told us that they might have been involved but they could not remember having a care plan. Another told us "I don't know about the care plan but they [staff] will help with anything".

People told us they had a choice in the way that care was delivered on a day to day basis. One person said "I usually get up in time for breakfast, but I have stayed in bed until 2pm because I didn't want to get up". Other people told us they are asked when they want to get up too. All of the people that we spoke with told us they were always asked whether they wanted a bath or a shower and that they were given their preference. One person told us they weren't sure if they could have a bath or a shower every day if they wanted one. Another person told us they did not have to wait for a bath or a shower, that they could have one when they got up.

One person told us that when they are taken to the bathroom for a bath or shower the care staff always ensured they took care and covered them up so that their privacy and dignity was maintained.

The people who use the service we spoke with told us that they feel safe in the home. Although most people did not know who to speak with if they felt that they had been put at risk.

No one was able to look after their own medicines so they were all given by staff. People we spoke with said they were happy with how their medicines were looked after. They told us that the times they were given their medicines sometimes varied depending on who was working. One person told us they were sometimes given their night time medicines later than they would have liked.

Two people told us they were always given their creams and ointments although we saw that often care staff had not recorded that they had done so.

We saw some medicines being given after lunch on both floors. These were given in a safe and respectful way.

People we spoke with told us that they felt there were enough staff within the home to care for their needs. People told us that their call bells are responded to in a timely manner by staff.

Reports under our old system of regulation (including those from before CQC was created)