Archived: Ocean Hill Lodge Residential Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question inadequate. At this assessment the rating has remained inadequate. This meant people were not safe and were at risk of avoidable harm.

At our last inspection we identified breaches relating to staffing, safe care and treatment and governance. At this inspection we found the service remained in breach of the same regulations.In addition, we identified a breach of regulations relating to recruitment processes.

Systems to learn from incidents and drive improvement were not robust. Staffing levels were not consistently maintained and staff were not always effectively deployed. Recruitment processes were not safe. Care plans and risk assessments were not updated to help ensure they reflected people’s needs. Medicines were not well managed.

This service scored 34 (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 have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

Systems to support learning from incidents were not robust. Since the last inspection systems to report and record incidents and accidents had been introduced. However, forms were not always accurately completed meaning information was unreliable.

There was no responsible person with oversight of incidents. A manager had recently left the service. The remaining registered manager, who was also the owner/provider, was unsure how to access audits or locate information we asked for. A newly recruited manager told us they were not familiar with the system being used to record information about the service.

There was little evidence of lessons learned processes being initiated following incidents. For example, one person had fallen 3 times in 3 consecutive months. Their falls risk assessment had not been updated.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Care plans were not always updated when people’s needs changed. This meant there was a risk that information that needed to be shared with other agencies might not be accurate. For example, if people needed to be admitted to hospital.

A visiting health professional told us the service communicated well with them and shared information about people’s health and well-being appropriately.

Most people told us they had visited the service prior to moving in and staying close to their local community was a priority for them.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Following the inspection a member of staff told us about a concern they had heard about relating to possible poor care, which they had shared with managers. This had not been reported to safeguarding or CQC. We raised this concern as a safeguarding alert.

Since the previous inspection staff, apart from those most recently recruited, had completed on-line safeguarding training. Face to face training had been arranged but cancelled, no alternative date had been arranged. Only 4 members of staff had completed training for The Mental Capacity Act (2005).

A relative told us; “I have no concerns regarding safety day to day.” People looked well cared for and were relaxed with staff.

The provider did not work well with people to understand and manage risks. Staff provided care to meet people’s needs that was safe and supportive. However, records in this area did not meet the required standard.

Since the last inspection care plans had been developed for everyone living at the service. However, these were not updated when people’s needs changed. For example, 1 person had fallen, and their leg was in a cast. This was not recorded in their care plan. Their falls risk assessment had not been updated. Another person sometimes had difficulty eating due to a medical condition. A speech and language therapy (SALT) referral had been made in December, but this had not been followed up. During the inspection we observed the person struggling to eat. Following the inspection the registered manager told us the referral would be chased up.

There were no care plans or associated risk assessments specifically for people with diabetes. This meant staff did not have access to information about potential signs and symptoms of deteriorating health and how to mitigate risks.

One person’s water had been turned off in their room and staff were required to carry hot water to the room from a different area of the service. There was no risk assessment to cover this practice.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Some improvements had been made to the environment since the last inspection. Boilers were now working. However, there were some trip hazards in people’s rooms such as sensor mat leads. The door to the laundry room was left open which meant people could have entered without staff knowledge. This presented a risk due to the cleaning products stored in the room.

A fire inspection took place at the same time as our inspection. Some concerns were identified, and the registered manager was told they must make improvements.

Health and safety checks were completed. For example, we saw a gas safety certificate, a legionella certificate and a satisfactory electrical installation condition report.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

There were not always enough staff to cover the rota. The registered manager had put themselves on the rota on occasion to achieve the required staffing levels. However, they had not completed training to enable them to provide personal care.

Since the previous inspection, 9 members of staff had left the service and a further 3 had handed in their notice. Three members of staff had joined the service, and 3 others were waiting for DBS checks to be completed before starting work. No exit interviews had been completed to try and improve staff stability. Following the inspection the registered manager told us they were in the process of recruiting 2 more staff.

Recruitment processes were not followed. Staff files did not contain the necessary information as required by the regulations. Gaps in employment had not been followed up at interview. Interview notes were sparse, and interview questions were not designed to establish candidates’ knowledge and skills. Two members of kitchen staff were working without Disclosure and Barring (DBS) checks. This had not been risk assessed. A member of the public contacted us to tell us about their experience of applying for a job at Ocean Hill Lodge. They told us they had concerns about how the process had been organised. They commented; “There were a lot of red flags, it was all really unprofessional.”

Oversight of staff performance was not robust. There were 14 staff employed to deliver care. Only 2 of these members of staff had received face to face supervisions in 2025, both in January. There was no schedule for further supervisions. Observations of staff practice had been completed and recorded for 5 members of staff. This meant the majority of staff had not received any professional support or guidance.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Processes to help ensure good food hygiene were not followed. Fridge and temperature checks were not consistently completed. Opening and closing checks which should have been completed at the beginning and end of the day were not being done.

Bedrooms and corridors were clean. However, we did identify malodours in one room.

There had been reports of vermin infestation in the premises. The registered manager told us they would not contact pest control until some repairs were made to the fabric of the building. This meant there was a risk infestation would become worse. Following the inspection the registered manager contacted a pest control service who did not identify any evidence of recent infestations.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. However, some improvements had been made since our previous inspection, and further improvements were planned.

There were suitable arrangements for ordering and storing medicines, including those needing cold storage and controlled drugs (CDs). However, there were some previous entries in the CD register where medicines returned to the pharmacy had not been signed out of the register. There had been no regular checks of these medicines, however a check had been recently recorded in the register, and we were told this would be done weekly going forward.

Timings of medicines rounds were not always suitable. There was a 3-hour gap scheduled between lunch and teatime rounds. Therefore, medicines needing a 4-hour gap between doses could be administered too close together. The times medicines were administered was not usually recorded, so it was not possible to be assured medicines were always given at correct times, or that safe dose intervals were maintained.

People’s medicines were recorded on Medicines Administration Charts (MARs) when administered. However, there were a few gaps in people’s records where there was no signature or reason recorded for omission of a dose. This meant it was not possible to tell if these doses had been given, or whether people had received their medicines as prescribed for them.

Improvements were needed to ‘when required’ medicines. There were protocols in place for most of these medicines to guide staff as to how and when they may be needed. However, these protocols were not always updated when changes were made to people’s medicines. There were separate charts to record the time, reason and outcome for administration of these medicines, but they were not always completed. This meant we could not be assured ‘when required’ medicines, including medicines to control pain, were being given as prescribed or according to people individual needs.

There were no risk assessments available for some high-risk medicines such as anticoagulants or flammable topical preparations to show people’s individual risks had been considered and acted on.

Creams and other external preparations were often recorded to be used ‘as directed’ without full directions to how and when they should be applied. Application charts for creams were not consistently completed. A monthly audit did not cover the completion of the application charts, so the provider had not identified this issue.

Staff received training in medicines handling, and competency checks were recorded to show they gave medicines safely. The manager told us these would be updated annually. There were forms for reporting errors however it was not always possible to tell what actions had been put in place or whether staff had their competency rechecked after an error as stated in the home’s policy. Medicines audits did not cover all aspects of medicines management and had not identified all the issues we found.