Archived: Ocean Hill Lodge Residential Care Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question inadequate. At this assessment the rating has remained inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

At our last inspection we identified breaches relating to safe care and treatment and governance. The service remained in breach of these regulations. In addition, we identified a breach of regulations relating to consent.

People’s nutritional needs were not supported. Monitoring records were not accurately completed. People were not supported in line with the principles of the Mental Capacity Act (2005).

This service scored 33 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

During the inspection the new manager was carrying out a pre-admission assessment. They told us they did not have any specific processes to follow and would just ‘ask a load of questions.’ Following the inspection the registered manager requested CQC agreement for one person to move into the service in line with conditions on their registration. The assessment highlighted some specific areas where the person would need support. The registered manager did not provide any information, or assurances, about how they would support the person in line with their specific needs.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

People were not supported to have healthy diets. The main meal was at lunch time and no choice was offered. On neither day of the inspection were fresh vegetables part of the meal. On the first day lunch consisted of thin sliced ham, egg and chips. On the second day lunch was sweet and sour chicken and rice. The chicken dish had been made with a ready-made jar of sauce. One person indicated they did not like the chicken dish and was given a bowl of tinned soup.

On the first day of the inspection there were no fresh vegetables in the service and only 3 pieces of fresh fruit. We were not assured people’s nutritional needs were being met.

The provider did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.

When there were concerns about people’s health and well-being staff made referrals to appropriate professionals. A visiting professional told us staff listened to any guidance they gave on how to maintain people’s health. They also said staff would ask for advice if they felt they needed to. However, one referral had not been followed up after a period of time. Monitoring records had not been used to identify when people’s health might have been declining.

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

People were not encouraged to move around or take part in any exercise. There was a lack of activities for people, this was also identified at our previous inspection.

The provider did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive andconsistent, or that they met both clinical expectations and the expectations of people themselves.

Monitoring records were incomplete. Bowel charts for April 2025 contained gaps. For example, in one person’s records no bowel movements had been recorded between 7 and 12 April or 14 to 19 April. It was not clear if this was a recording failure or not. There had been no escalation of concern. The lack of clarity meant people were at risk of developing constipation and not receiving the appropriate treatment.

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS).

One person had a DoLS authorisation with conditions attached which required staff to offer them activities and record each activity, whether they had accepted or declined the activity and any discussions about the activity to attempt to establish if they were enjoyable or meaningful. There were no activity logs in place. A member of staff told us they were unaware of the requirement.

The water in one person’s bedroom had been turned off following an incident when they had blocked the sink causing a small flood and water damage to a carpet which had to be thrown away. There was no documentation to evidence the decision to introduce this restriction had been taken in their best interest and was the least restrictive option. There was no associated risk assessment or information about how staff could ensure the person had access to drinking water.

A best interest decision record had been completed on 7 March 2025 relating to restrictions on visitors for one person. The decision had been taken following a request from a relative. However, there was no evidence the relative had the appropriate legal authority to make this decision on the person’s behalf. The form stated the person had not been encouraged to participate in the decision-making process. No independent stakeholders had been involved in the process. This meant there was a risk the person’s wishes relating to visitors were not considered.