Oak Farm

Oak Farm is nursing home providing rehabilitation to people living with brain injuries. The home can accommodate up to 32 people and at the time of the inspection was supporting 24 people. The service comprises of a main building which can accommodate up to 28 people and a smaller unit supporting four people. The service has a communal gym and gardens for people to access.

People’s experience of using this service and what we found

At our previous inspection we had highlighted concerns with record keeping and overall governance of the service. At this inspection we had found these areas had improved. People and their relatives were positive about changes that had been made.

People’s medicines were stored and administered safely. People received their medicines on time and as prescribed by healthcare professionals.

Care plans had been improved since our last inspection and were detailed about what people were able to do for themselves to promote their own independence.

Staff spoke about people in a caring way and were observed to be supporting people respectfully.

Staff were responsive to people and offered them timely support. People felt staff supported them well and were always available.

External healthcare professionals were contacted when required for the needs of people. Ensuring people received responsive input when needed.

Regular staff meetings and handovers were taking place to ensure peoples wellbeing was closely monitored and action taken when needed to keep them safe.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 23 December 2021) and there were breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Exiting special measures

This service has been in Special Measures since January 2020. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 19 October 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve the safe care and treatment of people as well as good governance of the service.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective, Caring and Well-Led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Oak Farm on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Oak Farm is nursing home providing rehabilitation to people living with brain injuries. The home can

accommodate up to 32 people and at the time of the inspection was supporting 24 people. The service comprises of a main building which can accommodate up to 28 people and a smaller unit supporting four people.

People’s experience of using this service and what we found

We identified continued concerns in relation to the governance and oversight of the documentation within the service. These areas caused risk to the people being supported due to records not always being clear or accessible to the staff team. Whilst regular auditing of documentation had been completed, this had failed to highlight areas we identified.

Mental capacity assessments were not fully completed on all occasions evidencing how the person’s capacity had been assessed to enable the least restrictive decision to have been reached. Capacity assessments lacked detail to evidence the person had been involved in the decision. Following the inspection the provider has introduced revised capacity assessments to add greater details.

Goals set for people were not always meaningful to that person. The quality of records made it difficult to track progress for each goal and lacked detailed involvement with the person to set the desired goal initially.

Cultural assessments were not sufficiently comprehensive, ensuring that the person’s spiritual needs or beliefs could be suitably met. There was a lack of detail how to support people with their chosen religion. Following our inspection the provider has implemented expanded cultural care records.

Care plans were not accessible to the staff team. These files were large in size and made finding key information challenging. This delay in finding information could cause potential risk to the person being supported in an emergency situation. Staff were not always clear on all areas of the care plans. This could lead to inconsistent support being offered to the person.

Staff were observed supporting people in a caring manner. Knocking on people’s doors prior to entering the room and offering choice where this was possible.

People were positive about the support they received and felt safe within the care environment. Families and visiting health and social care professionals were also positive about the service and felt communication had greatly improved.

Medicines were safely managed and the service was clean and well maintained when we visited. Staff were observed to be wearing the correct Personal Protective Equipment to keep themselves, and others safe.

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

Rating at last inspection and update:

The last rating for this service was Requires Improvement overall (published 31 March 2021), with Inadequate in Well-Led and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found some improvements had been made however, the provider remained in breach of the regulations associated with good governance.

The service has been in special measures since January 2020. During this inspection the provider demonstrated some improvements had been made. However these were not sufficient, and the service remains inadequate in well led due to continued breaches over five inspections. As such the provider remains in special measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so. Existing conditions of the providers registration will remain in effect.

We have identified breaches in relation to the risk assessing to keep people safe and oversight of the service in relation to the documentation completed to keep people safe.

Please see the action we have told the provider to take at the end of this report.

Follow up

Existing conditions served as an outcome of our last inspection will remain in place for this service.

We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures

The overall rating for this service is ‘Requires improvement’. However, the service will remain in 'special measures'. We do this when services have been rated as 'Inadequate' in any Key Question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Oak Farm is nursing home providing rehabilitation to people living with brain injuries. The home can support up to 32 people and at the time of the inspection was supporting 22. There is both a main building which can accommodate up to 28 people and a smaller unit supporting four people.

People’s experience of using this service and what we found

We had continued concerns around the provider’s governance structure. Only limited aspects of service delivery were audited to provide the information required for service improvement. The service needed to be more proactive at working with partner agencies and ensure it collected the views of the people they supported and their families.

We found continued concerns in that people’s care needs were not always effectively risk assessed and management plans, where developed, were not routinely followed.

Improvement had been made in both the safe recruitment of staff and the environment, which had been refurbished to allow for better infection prevention and control. Medicines were safely managed and families of people told us they were received, when needed, by staff who knew their role and were supported by a large enough team to meet their family’s other support needs.

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

Rating at last inspection (and update)

The last rating for this service was Inadequate (published 24 October 2018) and there were multiple breaches of regulation. At this inspection we found some improvements had been made however, the provider remained in breach of two of the regulations associated with safe risk assessment and good governance. We have also given two recommendations in relation to partnership working and gathering people’s views.

The service has been in special measures since January 2020. During this inspection the provider demonstrated improvements had been made. The service is no longer rated Inadequate overall but remains inadequate in well led due to continued breaches over four inspections. As such the provider remains in special measures.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 4 and 5 November 2019. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, fit and proper persons employed, the safe management of equipment and the premises, people’s nutrition and hydration needs and the governance of the service.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements except regulation 14 which was also breached. Whilst we did not check the entirety of this regulation, we ensured people’s nutrition and hydration needs were safely managed under regulation 12.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Oak Farm on our website at www.cqc.org.uk.

We have found evidence that the provider needs to make improvement. Please see the safe and well led sections of this report.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safe care and treatment and the action the provider took to ensure the service delivered met the needs of the people living there. We issued a notice to place conditions on the providers registration. The conditions were aimed to assure us the provider took the required action to keep people safe. The provider must send the Care Quality Commission monthly reports on how they are monitoring and managing the risks to support people's health and wellbeing.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures:

The overall rating for this service is ‘Requires improvement’. However, the service remains in 'special measures'. We do this when services have been rated as 'Inadequate' in any Key Question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Oak farm is a Nursing home and rehabilitation support unit providing accommodation, personal and nursing care to up to 32 people living with a brain injury, under the age of 65. At the time of the inspection the service was fully occupied supporting 32 people.

People’s experience of using this service and what we found

Risks to people’s safety had not been adequately assessed or reviewed. We identified that equipment was in use that should have been removed from service due to safety issues. Staff did not ensure pressure relieving equipment was used safely and in accordance with the assessed settings.

People were not protected in a safe environment. The premises were unclean in places and not maintained to a standard which ensured people were safe. We identified risks in the environment which had not been recognised or addressed by staff or the management.

The management of medicines had improved since our last inspection, but we found improvements were still required in record keeping, ensuring safe application of pain-relieving patches and administration of controlled drugs. Improvements needed to be made to the providers recruitment processes to ensure suitable staff were employed to work at the service.

We identified insufficient monitoring and oversight of people’s nutrition and body weight, including where people used a feeding tube and did not eat orally. Action was not always taken when peoples body weight began to decline. Improvements had been made to staff training and supervision of their practice. People felt staff were competent.

We were not assured that people were always supported to have maximum choice and control of their lives and that staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported did not support best practice.

People told us the staff were caring and kind towards them. However, staff did not always promote people’s dignity to ensure their right to privacy was upheld. People were not always involved in all aspects of their care planning, we found that goals had been identified in care records for people without their input.

Care records did not always provide sufficient detail to guide staff on how to look after people and were not updated when peoples needs changed. Regular reviews of care records to ensure they remain relevant were missed. Staff understood how to support people in line with their communication needs. People had the opportunity to be involved in activities within the service and local community. People understood how to complain and told us concerns had been acted on. Plans were in place to give staff guidance on how people wished to be supported at the end of their life

There was a lack of clear governance in the service and the provider did not have effective systems in place to consistently assess, monitor and improve the quality of care. This meant poor care was not identified and rectified by the provider. Our two previous inspections have rated the service as Requires Improvement and the service is now rated Inadequate. We are therefore concerned about the overall governance of the service.

Rating at last inspection

The last rating for this service was requires improvement (published 11 October 2018) and there were multiple breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

We found concerns during this inspection and there were repeated as well as new breaches of regulations. We rated the key questions safe and well led as inadequate. The key questions Effective, Caring and Responsive were rated Requires Improvement. The overall rating is Inadequate. This is based on the findings at this inspection. This is the third consecutive inspection where the provider has failed to obtain a rating of Good.

You can see what action we have asked the provider to take at the end of the full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Oak Farm on our website at www.cqc.org.uk.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least Good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Oak Farm is a ‘nursing home’ and a rehabilitation support unit which provides care and support to people who are living with a brain injury. At the time of our inspection there were 36 people living at Oak Farm. The provider has on site a multi-disciplinary team which includes a physiotherapist and two part-time occupational therapists as well as therapy and activity assistant staff, nurses and care staff. People in care homes receive accommodation and nursing, personal care or rehabilitation as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Oak Farm accommodates people in two adapted buildings across a one floor. There were 36 people living in the home when we inspected, many of whom were living with complex health conditions including the effects of traumatic brain injury.

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 registered manager was not available at the time of our inspection, and we were supported to carry out the inspection by other members of staff, such as administration, the area manager, the care coordinator and the clinical lead.

At our last inspection of 31 May and 2 June 2017, we found that staff did not always obtain consent from people. Improvements were needed with regards to the management of medicines, staff training, mealtimes and systems for monitoring the service.

At this inspection, staff obtained consent from people before delivering care. Staff understood people’s mental capacity and supported them to make decisions.

There had been improvements in the management of medicines, and there were protocols in place when needed. However, further improvements were needed in the administration of topical medicines.

We found at this inspection on 3 September 2018 that further improvements were needed in respect of the quality monitoring of the service. The systems for identifying issues and monitoring the service were not fully effective. Medicines audits had not identified that there was limited and inconsistent recording around some prescribed items, and the auditing process did not include checking the medicines administration records (MARs).

Improvements were needed to ensure that care plans remained up to date and relevant, as they did not always contain sufficient information about people’s needs. For example, in some areas such as communication, skin integrity and activities or occupation.

There were enough staff to keep people safe and they had received some further training related to supporting people living in the service. However, further improvements were needed in this area, as some poor practice remained relating to manual handling. Staff felt supported in their roles.

There were improvements in staff supporting people in a caring way, however some poor practice remained. Staff were caring towards people’s families.

Staff knew how to report safeguarding concerns and there were health and safety checks which contributed to keeping people safe.

People received a choice of food and enough to eat and drink. They were also supported to access healthcare. People received in house treatment from nurses, physiotherapists and occupational therapists according to how the service was commissioned for people.

There were trips out and group activities held in the home, such as gardening and word games. Therapy staff worked with some people, for example on their mobility.

People and their families knew how to raise a concern or make a complaint, and these were responded to. Feedback was sought from people in the form of surveys, and feedback had been used to make some improvements to the service.

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.

At this inspection we found that the provider was not meeting the requirements of three Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because people’s medicines were not always managed safely, and there was not always an adequate skill-mix of staff deployed across the home. We also found that there were not fully effective systems in place to monitor the service and identify potential problems. You can see what action we told the provider to take at the back of the full version of the report.

Staff did not routinely obtain verbal or implied consent before delivering care, and care was not always delivered in a compassionate manner. Staff did not take opportunities to give people choices, however where people had made choices, these were respected.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) Deprivation of Liberty Safeguards (DoLS) and report on what we find. Mental capacity assessments had been carried out for specific decisions where appropriate and some people had been lawfully deprived of their liberty.

Improvements were needed with regards to the administration and management of medicines. Some medicines were at risk of being given inappropriately and stock levels did not correspond with records.

Improvements were needed with regards to staff training in challenging behaviours, manual handling and supporting the specific complex needs of the people at Oak Farm.

The systems in place to monitor, analyse and improve the service and identify concerns were not always effective.

We found that improvements were needed to the mealtime experience for people as staff did not always support them in a dignified, compassionate and interactive way, to eat their meals.

Staff supported people to eat special diets when they needed, and to drink enough. Staff also supported people to access healthcare when they required. There were enough staff to keep people safe and there were safe recruitment strategies in place. However, there was not always an adequate skill mix of staff available to meet people’s needs. People were supported to access healthcare promptly when they needed it.

There were comprehensive care plans in place for people and staff delivered care to individuals that met their specified preferences. The therapy staff supported people to maintain their mobility and to set and achieve goals. There were activities that people could get involved in during the week, and people were supported to access the community.

There was not always visible leadership in place throughout the home, however the staff worked as a team and were supported by the management team. People were not always asked for feedback in a way that they understood, however people knew how to complain.