Archived: Ocean Hill Lodge Residential Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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 leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

At our last inspection we identified breaches of regulations relating to governance and the requirement to notify CQC of specific events. The service was no longer in breach of the requirement to submit notifications. However, they remained in breach of the regulation relating to governance.

Governance systems were not effective in identifying the concerns we identified during this assessment. The registered manager did not have the skills, knowledge and understanding they needed to deliver a service that provided safe care and treatment to people living at the service. Care was task focused and not personalised. The registered manager did not have an understanding of auditing systems or the importance of safe recruitment. The service had failed to involve people, their representatives and staff in developing the service. Despite being supported to improve the service had not undertaken the necessary changes and ensured these were well established to help ensure people received safe and high-quality care.

This service scored 29 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and needs of people and their communities.

The registered manager did not demonstrate an understanding of the processes and systems required to operate a safe and responsive service. Actions had been taken immediately after the previous inspection, but these had not been progressed or any learning taken from the experience. For example, care plans had been developed for people but not updated when people’s needs changed.

Recruitment processes were not operated to help ensure staff were suitable to work in care. We asked the registered manager to complete risk assessments to cover staff without DBS checks in place, working in the kitchen. They forwarded us emails they had sent to the staff requesting them to confirm they would not interact with people until their DBS checks were returned. These were not risk assessments and demonstrated a lack of understanding of the process.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

The registered manager did not have the necessary skills and experience to oversee the service effectively. A manager had recently left. Although the registered manager told us they had completed a handover with them they were unable to locate information we requested or access audits. Throughout the inspection they needed to text the previous manager to ask questions about information we had requested.

There was not always a manager or deputy manager available in the service. Rotas for the first week of May showed there were 2 full days when there was no manager or deputy working. During the inspection visit the manager had to leave the service to carry out an assessment and do a food shop. A member of staff commented; “Where is the manager, who is in charge; is it me? The manager is not here and the deputy is not here.”

People did not feel they could speak up and that their voice would be heard.

Staff meetings had been held since the last inspection. One member of staff told us they had raised concerns at previous meetings but “nothing ever got followed up.” Another member of staff said they had highlighted a concern to managers but felt the response had not been supportive. One member of staff told us the registered manager could be unpredictable. They commented; “It can be tense when [registered manager] is here because you don’t know what they’re going to be like.”

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff told us they did not always feel valued. Since the previous inspection improvements had been made to how staff were paid and there had been no further late payments. However, not all staff had received all their payslips and were still waiting on this documentation.

Systems to support staff involvement were not well-established. Some staff had received one to one supervision. However, they had not seen any records of these meetings and had not been asked to sign them.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

At our previous inspection we imposed urgent conditions on the provider requiring them to submit monthly reports to enable us to monitor the service. While some improvements had been made in staff training and care planning there remained areas of significant concern. Submitted reports had given assurances about oversight of accidents and incidents. However, during this inspection, we found information on accident forms was incomplete or inaccurate. The electronic system stated all information should be entered on a spreadsheet to provide an overview and facilitate effective auditing. The registered manager was unable to show us the spreadsheet. Following the inspection visit they provided us with a Word document which listed accidents and incidents in January. We were not assured the system was effective or properly used to drive improvements and mitigate risks.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

Since our previous inspection the service had received considerable support from the local authority quality assurance team. Despite this, improvements had not been embedded, and the local authority were continuing to support the service.

The service did not work with local manager forums to share learning and experiences. Following our previous inspection an improvement manager had been contracted to drive the necessary improvements. However, they had only been commissioned for a few weeks. A manager recruited at the same time had left the service shortly before this inspection. A relative described the service as ‘unstable’ and a member of staff commented; “I cannot believe within a year what has happened to [Ocean Hill Lodge]. So many corners have been cut.” Staff recognised the service lacked effective leadership and that performance had not significantly improved following the last inspection.

The registered manager was not based locally and spent most of their time away from the service. However, they told us they did not want to delegate responsibilities to the new manager and told us they would continue to oversee decisions about the service themselves. This meant the manager might have been unable to take day to day decisions about the running of the service, delaying action.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

We identified a reactive approach to running the service. The provider responded to issues raised by CQC or the Local Authority. For example, following the inspection visit they contacted pest control, replaced some old towels and followed up information about recruitment. However, there was limited evidence of learning. The registered manager was not proactive in identifying areas for improvement. We were not assured the service would continue to improve without ongoing support.