During an assessment under our new approach
Date of assessment: 22 April to 28 April 2025.
The inspection was carried out to check if improvements had been made following our last inspection when we identified breaches of regulations relating to person-centred care, safe care and treatment, management and oversight of the service, staffing and a failure to submit statutory notifications. Following the inspection, we imposed conditions on the provider’s registration. At this inspection, the provider was no longer in breach for failing to submit notifications. However, we found repeated breaches of regulation relating to person-centred care, safe care and treatment, management and oversight of the service and staffing. We also identified breaches of regulations relating to consent and safe recruitment.
We assessed all quality statements under the 5 key questions; Safe, Effective, Caring, Responsive and Well-led. The service is a residential care home providing support to up to 18 older people. At the time of our inspection 11 people were living at Ocean Hill Lodge.
There were not always enough staff with the relevant skills and experience to provide safe care. Systems to help ensure newly employed staff were suitable to work in the care sector were not consistently implemented. Care plans had now been developed for everyone living at the service, but these were not updated when people’s needs changed. Improvements were needed to the way medicines were managed. Monitoring records and accident and incident forms were not accurately completed.
The provider/owner was also the registered manager. Throughout this report we will refer to them as the registered manager. They were not experienced in using the service auditing systems and were not able to locate all the information we required.
People did not have daily choices about how they spent their time and what they ate. There was a lack of fresh food available for people. People were not supported in line with the principles of the Mental Capacity Act.
Despite the support the service had received we were not assured improvements had been made or become established in order to ensure people received the safe and person-centred care they were entitled to.
In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded. This service remains in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.