Oakhill House Care Home

Oakhill House Care Home is a residential care home providing personal and nursing care to up to 49 people. The service provides support to older people and people living with dementia. At the time of our inspection there were 30 people using the service. The home was set over two floors, however the top floor was not in use.

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

People had not always been protected from the risk of harm and abuse. The provider had recently identified safeguarding concerns reported by staff between 2020 and 2021 which had not been investigated at the time of the incidents or reported to the appropriate agencies externally. Once these incidents had been found, investigations and analysis of each incident had been completed as far as possible and measures put into place to minimise the risk to people. Incidents were reported retrospectively to the local authority safeguarding team, CQC, Police and people's relatives.

Risks to people were not always safely managed. The provider had recently found incidents relating to people's safety that had not been investigated or reported. These included incidents of falls, serious injuries and choking events. Although action had been taken in response to finding these incidents, we found that further improvement was needed around managing people's risks. People at risk of choking had not always been safely supported in line with guidance provided by healthcare professionals.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. The provider had identified an historic incident in which a person had been unlawfully restrained. This incident had not been reported in a timely way. The provider had investigated the incident and ensured that staff understood their responsibilities around the Mental Capacity Act.

Governance systems had not been effective in identifying recent concerns at the service regarding the reporting of incidents. The provider's response to finding these incidents was not prompt or in line with their safeguarding policy. Some improvements were needed to record keeping to ensure that people at risk of malnutrition, dehydration and skin breakdown were kept safe.

People and their relatives were positive about the support provided by staff at the home. Staff were kind and caring and treated people with dignity and respect. Staff had been safely recruited and trained to support people. People, relatives and staff were given opportunities to feedback on the quality of care at the home. Staff worked with other professionals to provide joined up care for people.

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

Rating at last inspection

The last rating for this service was good (published 03 April 2020).

Why we inspected

We received concerns in relation to safeguarding and safe care and treatment. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

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 good to requires improvement based on the findings of this inspection. We have found evidence that the provider needs to make improvements. Please see the safe, effective and well led sections of this full report.

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

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 Oakhill House Care Home on our website at www.cqc.org.uk.

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 monitor the service and will take further action if needed.

We have identified breaches in relation to safeguarding people from abuse, safe care and treatment and governance.

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

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Oakhill House Care Home is registered to provide nursing care and support to a maximum of 49 people; 34 people were living at the service at the time of our inspection. The service is for older people, who may be living with a physical disability and/or dementia.

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

People told us that staff were caring and compassionate in their approach. One compliment seen stated, “From the manager and reception down to every grade of staff, the home shows they are a caring and committed bunch who go out of their way to make everyone feel welcome.”

People were treated with kindness and emotional support and their independence was promoted by staff. People were treated with respect and dignity and supported to make decisions about their care.

People told us they felt safe at the home. Risks to their health and wellbeing had been assessed and actions put in place to reduce those risks. People were protected from harm and abuse from staff who were knowledgeable about safeguarding. People were protected from the spread of infection through effective and safe control measures.

Risks to people’s physical and mental wellbeing had been assessed and staff ensured that these risks were reduced as much as possible. People were supported by enough skilled and trained staff to meet their needs. Training was provided to staff in order to meet the needs of people at the home. People’s nutritional and hydration needs were met and monitored for those who were assessed as being at risk.

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.

People told us that there had been a definite improvement in the activities and engagement at the home. People’s views were listened to and acted upon and they and their relatives felt confident that concerns would be acted upon.

People, staff and relatives spoke positively about the registered manager. Management was approachable and open to feedback and discussions about people’s care. The quality of people’s care was supported by effective quality assurance systems.

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

Rating at last inspection

The last rating for this service was requires improvement (published 11 April 2019). At this inspection, the service had made improvements and the rating had improved to good.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Oakhill House Care Home is registered to provide nursing care and support to a maximum of 49 people. 26 people were living at the service at the time of our inspection. The service is intended for older people, who may be living with a physical disability or dementia.

People’s experience of using this service:

People told us and we observed that they were safe and well cared for and their independence was encouraged and maintained. Comments included, “This is a good place to live, I feel safe.”

• The service had made improvements since our last inspection. This meant people’s outcomes had improved. However, whilst the provider had progressed quality assurance systems to review the support and care provided, there was a need to further embed and develop some areas of practice that the existing quality assurance systems had missed. For example, an external Legionella and Water Safety Risk Assessment in December 2018 had made recommendations that required action within a certain time frame. There was no improvement plan relating to the work and the water checks on the empty floor were irregular.

• People’s safety was not always protected. The security of the building needed to be reviewed, to ensure people could not enter unannounced.

• The lack of opportunity to provide meaningful activities was known but not yet acted on, or a plan put in place to address this.

• These were areas that required further improvement.

We have made a recommendation about seeking expert advice about the administration and use of medicines given covertly (disguised in food/drink).

We have made a recommendation about seeking expert guidance regarding oral hygiene practices.

• People were protected against avoidable harm, abuse, neglect and discrimination. The care they received was safe.

• People's health risks were assessed and strategies put in place to mitigate the risks.

• Staff received improved supervision and training since our last inspection, which provided them with the knowledge and skills to perform the roles they were employed to do.

• People received their care and support from a staff team, who had a full understanding of people's care needs and the skills and knowledge to meet them.

• Staff were given an induction when they started and had access to a range of training to provide them with the level of skills and knowledge to deliver care efficiently.

• People and relatives provided consistently positive feedback about the care, staff and management. They said the service was safe, caring and well-led.

•Staff treated people with respect and kindness at all times and were passionate about providing a quality service that was person centred.

• People's care was more person-centred. Care delivery was designed to ensure people's independence was encouraged and maintained.

• People were involved in their care planning.

• There was a happy workplace culture and staff we spoke with provided positive feedback.

The service met the characteristics for a rating of Requires Improvement.

More information is in our full report.

Rating at last inspection: Requires Improvement. (Report published on 6 November 2018.)

This is the second time the service has been Requires Improvement. However, improvements were seen and there were no breaches of regulation.

Why we inspected:

• As part of our enforcement action following our prior inspection, we served a warning notice and this inspection was scheduled to look at their action plan and ensure improvements had been made.

• All services rated as ‘Requires improvement’ are re-inspected within one year of our prior inspection. This inspection was part of our scheduled plan of visiting services to check the safety and quality of care people received and the improvements made.

Follow up:

• We will continue to monitor intelligence we receive about the service until we return to visit as

per our re-inspection programme. If any concerning information is received we may inspect sooner.

Oakhill House Care home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home can provide accommodation and nursing care for 49 people in one detached building that is adapted for the current use. The home provides support for people living with a range of healthcare, mobility and sensory needs, including people living with dementia. There were 32 people living at the home at the time of our inspection.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered managers, 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.

This was the first inspection of Oakhill House Care Home since HC-One Oval Limited became the provider of the service and registered it with the Care Quality Commission in December 2017. At this inspection we identified areas that required improvement, including breaches of regulation in relation to ensuring staffing levels, safe care and treatment arrangements, quality assurance and governance systems were sufficient to enable staff to meet people’s preferences and care needs.

We were told that staffing levels had been assessed based on people’s care and support needs and that the service was working towards establishing more consistency in relation to the use of agency staff and recruiting. However, people, relatives and staff felt that there were times when there were insufficient staff or inefficiently deployed staff to ensure people’s preferences and care needs were met. One relative told us, “I have no experience of any other home to compare this to but they have a lot of people who need a lot of care. There are times when I come and it’s clear my relative needs changing but they have been left sitting there for a while because it’s either not time for the toileting round or not their turn. They get distressed then. I think the staff do their best but there’s not enough of them.” Our own observations in relation to people’s mealtimes, access to activities and communal spaces supported this.

People had not always been provided with suitable arrangements for their end of life care to ensure they could experience a respectful, comfortable, pain free, end of life. The provider had learnt lessons in relation to one person’s experiences and had refreshed staff awareness and training but people’s end of life preferences had not been fully embedded in their care planning. The provider was reviewing its pre-admissions processes to ensure that suitable assessments of need were in place and that relatives were fully consulted where they had the right to be.

Quality assurance systems were in place and being embedded. The provider had used these proactively since March 2018 to monitor the overall quality of the home and to identify any shortfalls and improvements necessary. However, during the four months before this date and as the systems were embedding the provider had not fully ensured that people were protected from the risk of harm or that risks were managed safely. People’s dignity and right to have their preferences met in relation to end of life care, eating and activities were also not consistently respected. People’s access to sufficient staffing levels and the consistency of their personal care need being met were not always ensured.

People were not always protected from the potential risk of abuse. Staff could demonstrate a good understanding of their safeguarding responsibilities and were confident that if they raised concerns they would be treated seriously. However, in relation to two complaints made by relatives involving people’s wellbeing the registered manager did not effectively identify that abuse may have occurred. A social care professional fedback that the area quality director had demonstrated a good understanding of safeguarding and was keen to work to improve the home. However, they also fedback that the registered manager had not always demonstrated a full appreciation of risk in relation to safeguarding.

Staff and the registered manager told us that they had not had much support or contact with the new provider until the area quality director and area director were recruited to. They described that the culture of the service was of a home in transition.

Communication at the home was not consistently effective. Staff and relatives told us that communication with the new provider had been poor after they had initially taken the service over in December 2018. Relatives and staff told us this had improved at the home since the area director was in post in March 2018. The registered manager had addressed and investigated relative’s complaints since January 2018. However, relatives told us and discussed in their complaints that the registered manager had not always communicated in a timely way in relation to their concerns and had not always been accessible when they visited.

People’s right to privacy and dignity was not always respected when they were in their bedroom. However, we did observe some areas of good practice in relation people receiving care and staff demonstrated a good understanding of how to maintain people’s privacy and dignity.

The provider had arrangements in place for the safe ordering, administration, storage and disposal of medicines. People were supported to have their medicine safely when they needed it. Medicines were consistently administered safely and audits identified where improvements could be made. Staff gave medicines respectfully having gained consent.

The registered manager completed risk assessments and a programme of regular health and safety checks to ensure quality was measured and maintained. We observed audit activity for areas including, medicines, and fire safety and infection control. Staff recruitment processes continued to ensure that new staff were safe to work with people

The building was being refurbished and decorated to make it more dementia friendly. The homes dementia champion was actively promoting improved dementia awareness through training staff and introducing the use of memory boxes. Memory boxes can be added to by the person and families and staff told us these memories can stimulate the person, prompting conversation linked to people’s life time experiences.

Information for people and their relatives was provided in an accessible format to meet their needs including their cultural presentations. For example, one person was bilingual, however was beginning to revert at times to their first language due to their dementia

Staff we spoke with understood the requirements of the MCA and people had access to advocacy services to promote their choice and rights in line with legislation. People were supported in line with the principles of the Mental Capacity Act (MCA) 2005.

Staff demonstrated a good knowledge of people’s individual needs, backgrounds, preferences and likes and dislikes and had a genuine regard for their wellbeing. People were comfortable spending time with staff who spoke with them in a patient and caring manner.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

The service did not have 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. A manager was in post on the day of the inspection and they had been in post four weeks. They told us that they would be submitting an application to become the registered manager and subsequent to the inspection, we were informed that the manager had submitted an application to become the registered manager.

At the last inspection undertaken on the 19 and 20 June 2017, the provider was in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014. This was because accurate and complete records had not been maintained. Recommendations were also made in relation to the administration of medicines. The provider sent us an action plan stating they would have addressed these concerns by October 2017. We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Oakhill House Care Home on our website at www.cqc.org.uk

The inspection was prompted in part, by a notification of a serious injury involving a person who lived at the service. The incident is subject to an investigation and as a result this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident, indicated potential concerns about the management of risk in relation to falls.

The management of falls was not consistently safe. The provider was not consistently following their internal falls protocol and procedure. Where people had been assessed at high risk of falls, falls care plans were not consistently in place. Guidance did not always document the measures required to mitigate the risk of people falling.

Steps had been taken to drive improvement and the provider was now meeting the legal requirements. The administration of medicines was safe and care documentation had improved. However, further work was required to strengthen the provider's internal quality assurance framework. The care planning process failed to consistently identify and reflect how staff respected and upheld people’s equality and diversity. Care plans failed to consistently identify people’s involvement with the design and formation of their care plan. Systems were in place to determine staffing levels. Steps had been taken to recruit additional staff and the use of agency staff was reducing. However, staff members felt staffing levels were insufficient and a struggle. We have identified these as an area of practice that needs improvement.

Staff worked in partnership with other healthcare professionals to promote good outcomes for people. Where people displayed behaviours which challenged, staff completed behavioural observation charts; however, the findings from the behavioural charts did not consistently feed into the care plan and risk assessments. We have identified this as an area of practice that needs improvement.

People were protected from harm and abuse. There were appropriate, skilled and experienced, permanent staff who had undertaken the necessary training to enable them to recognise concerns and respond appropriately. Staff were checked before they started working with people to ensure they were of good character and had the necessary skills and experience to support people effectively. There was a whistle-blowing procedure available and staff said they would use it if they needed to. People's medicines were managed appropriately and people received their medicines as prescribed by health care professionals.

Systems were in place to gain feedback from people, staff and relatives on the running of the service. Staff successes were celebrated. The service was subject to a period of change and the senior management team were dedicated in supporting staff, people and their relatives through the period of transition.

A dedicated team of housekeepers were available and systems were in place to prevent the risk of infection. Infection control policies and procedures were in place alongside plenty of personal protective equipment (PPE). Risks associated with the environment were managed and people's ability to evacuate the building had been considered and assessed as part of the service's fire safety risk assessment.

During our inspection we found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the registered provider to take at the back of the full version of the report.

There was a manager in post who was registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC 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. On the days of the inspection, the registered manager was away and the service was being overseen by a regional management team.

At the last inspection undertaken on the 23 February 2016 we identified a breach of the Health and Social Care Act 2008 (Regulated Activities) 2014 in relation to the management of people’s medicines. This was because medicines were not stored correctly, not everybody had access to their medicines and the recording of topical creams was inconsistent. A recommendation was also made in relation to people’s dining experience. The provider sent us an action plan stating they would have addressed all of these concerns by July 2016. At this inspection we found the provider had made improvements to people’s dining experience and to the management of medicines.

Systems were in place for the ordering, storage and disposal of people’s medicines. Each person had a medicine profile and people and their relatives confirmed they received their medicines when required. However, the administration of topical creams was inconsistent. Medication Administration Records (MAR charts) failed to consistently reflect if people were administered their topical cream as prescribed. The provider’s quality assurance framework had identified this shortfall, yet no action had been taken. Nursing staff were regularly disrupted when administering medicines which posed a risk. Nursing staff also confirmed they felt this was an area of concern. We have identified this as an area of practice that needs improvement and have made a recommendation for improvement.

Arrangements were in place for the provision of meaningful activities and stimulation. However, these arrangements were not yet consistently embedded into practice. Steps were being taken to reduce the risk of social isolation, but these required strengthening. We have identified this as an area of practice that needs improvement.

Appropriate recruitment checks took place before staff started work. Staffing levels were based on the individual needs of people and sufficient staffing levels were being maintained with regular use of agency staff. Staff felt staffing levels could be tough at times but agreed that despite these struggles, people received good care. The provider was actively taking steps to minimise the use of agency staff.

Oakhill House Care Home had been subject to a period of instability. Staff told us that morale had been low but confirmed things were starting to improve. The provider’s regional management team were supporting the service. A quality assurance system was in place and clear actions had been identified on how to drive improvement. However, these positive improvements were not yet embedded or sustained.

People told us they felt safe living at Oakhill House Care Home. One person told us, “I feel safe because everyone is very nice to me and they know my name. I have a bad memory but they all recognize me and nobody is quarrelling.” Staff worked in accordance with people's wishes and people were treated with respect and dignity. It was apparent that staff knew people's needs and preferences well. Positive relationships had developed amongst people living at the service as well as with staff.

Staff were kind and sensitive to people when they were providing support and people had their privacy and dignity considered. Individual risks to people were assessed and reviewed. Whilst encouraging people to maintain independence when possible, people's choices and wishes were supported. Management and staff had a good understanding of mental capacity assessments (MCA) and Deprivation of Liberty Safeguards (DoLS). Staff demonstrated a clear understanding of how to recognise and report abuse.

People were encouraged and supported to eat and drink well. There was a varied daily choice of meals and people were able to give feedback and have choice in what they ate and drank. Where people were at risk of dehydration or malnutrition, staff worked in partnership with healthcare professionals. Staff were knowledgeable about people's behaviours which might challenge and areas of care which might pose a risk to people. Staff recognised the importance that soft toys can bring to people living with dementia and interacted with people through their soft toys.

All required maintenance and servicing of equipment had taken place. Fire evacuation plans and personal evacuation procedure information was available in event of an emergency evacuation. People's confidentiality was maintained by staff and records were kept securely with only those with authorisation having access to them. People's right to make a complaint or comment was welcomed and acknowledged and action had been taken in response to people's concerns.

During our inspection we found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the registered provider to take at the back of the full version of the report.