Archived: The Oasis

The Oasis is a residential care home providing personal and nursing care to 30 people aged 65 and over at the time of the inspection. The service can support up to 35 people.

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

There were effective systems in place for the management of medicines which meant they were no longer in breach of regulations.

Medication Administration Records (MAR) showed people received their medicines as prescribed and these records were completed accurately. Guidance was in place for staff to follow when people were prescribed medicines to be administered on an 'as required' [PRN] basis. Staff had been trained to administer medicines and had been assessed as competent to do so safely.

Quality assurance and governance systems had been embedded into practice and were used effectively to drive improvements within the service. People, relatives and staff told us they felt the service was well led. There was a positive culture in the service where staff worked together towards the best outcomes for people.

People and their relatives told us they were safe living at The Oasis and there were appropriate systems in place to protect people from the risk of abuse.

Care plans and risk assessments provided staff with the information they needed to manage risk and keep people safe.

The premises were clean and tidy. Infection prevention and control measures and practices were in place to keep people safe and prevent the spread of infections. Staff had received infection control training. They had access to sufficient stocks of personal protective equipment (PPE).

The service followed safe recruitment practices and people were cared for by sufficient numbers of staff to ensure that people's care needs were met.

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 16 August 2019).

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.

Why we inspected

The inspection was requested by the provider as they were concerned their current rating was having an impact on their business.

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.

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.

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 requires improvement to good. 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 The Oasis on our website at www.cqc.org.uk.

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.

The Oasis is a residential care home in Plymstock. The Oasis can accommodate a maximum of 35 older people in one adapted building over two floors. At the time of the inspection, 26 people were living at the service. Some people may be living with dementia. Nursing care was provided by the local community nursing teams. community nurses.

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

Aspects of medicine management were not safe at the time of the inspection. The service had changed to an electronic system which had caused some difficulties. We found that a stock count of one person’s medicines were not correct. Protocols were not in place for people who required additional medicines, for example for pain relief and anxiety. People’s skin cream charts were not fully completed. The provider took action during the inspection period to start to improve medicine safety. Improvements included a new audit based upon best practice and increased monitoring of this area until robust, safe systems were in place.

People received person-centred care which was responsive to their specific needs and wishes. Each person had an up to date, personalised care plan, which set out how their care and support needs should be met by staff. Assessments were regularly undertaken to review people's needs and any changes in the support they required. Any needs in relation to the Equality Act 2010 were specified in care plans and if required, assessments detailed any support people required in relation to the Accessible Information Standard (AIS). The Accessible Information Standard aims to make sure that people who have a sensory loss, disability or impairment get information they can access and understand.

People had access to a wide range of group and individual activities and events they could choose to participate in, for example, music and dancing, conversation club and knitting. Special days were held for example a 1940s celebration day.

When people were nearing the end of their life, they received compassionate and supportive care. People's end of life wishes were sensitively discussed and comprehensively recorded.

Staff were aware of people's communication methods and provided them with any support they required to communicate. This helped ensure their wishes were identified and they were enabled to make informed decisions and choices about the care and support they received.

The service had appropriate arrangements in place for dealing with people's complaints if they were unhappy with any aspect of the support provided at the home. People and their relatives said they were confident any concerns they might have about the service would be appropriately dealt with by the registered manager and provider.

People were kept safe at the home and were cared for by staff that were appropriately recruited and knew how to highlight any potential safeguarding concerns. Risks to people were clearly identified, and ongoing action taken to ensure that risks were managed well. The provider ensured that incidents and accidents were recorded and fully investigated. The home was well kept and hygienic.

Staff were well supported through training, supervision and appraisal. Staff worked effectively together to ensure people's needs were communicated and supported them to access healthcare professionals when they needed them.

People enjoyed the meals available to them, were involved in menu planning and were appropriately supported with eating and drinking where required. 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.

The home was dementia friendly and met the needs of the people living there. A dementia “Champion” kept up to date with best practice. Staff could demonstrate how well they knew people.

People and their relatives were very positive about the care provided. People were treated with privacy and dignity and supported to be as independent as possible whilst any differences or cultural needs were known and respected.

The service had a management structure in place, and quality assurance systems were being embedded in order to drive improvements across the home. Feedback about the new leadership at the service was very good. The provider and registered manager knew people well. Regular feedback was sought from people and their relatives to ensure they were involved in the development of the service.

The last comprehensive inspection of this service was Requires Improvement (published July 2018) and there were multiple breaches of regulation. The provider completed an action plan to address our immediate concerns and we checked progress at a focused inspection in October 2018. The last rating for this service was requires improvement (published 4 December 2018). The provider completed an action plan after this inspection to show what they would do, and by when to improve.

At this inspection we found improvements had been made to how risks were assessed and mitigated, but we found concerns related to the management of medicines. Although immediate remedial action was taken to start address concerns, the provider was still in breach of regulations.

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

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified a breach in relation to medicine management at this inspection.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of medicines management. 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.

Prior to the inspection we had received new information of concern. One of these concerns was in respect of people being supported out of bed early so the day staff would have more time to do other duties. We arrived early to look at this and found this was not a concern. We noted three people were up early. We talked with one person and asked them if they liked getting up early. They replied, “I go to bed early and am ready to get up early”. We walked around the service and noted that some people were still in bed, some getting up and other people waiting for support from staff. We spoke with a member of the night staff who said, “We only get people up who have requested it”.

We shared other concerns we had received with the registered manager to which they were able to respond appropriately to. These were about how the service was staffed; how staff delivered personal care; how a person’s skin had been looked after; how staff spoke to one person negatively, how a person’s medicines were being recorded and, infection control measures in the kitchen. They advised us the director of compliance would be advised of these concerns and would communicate with us.

Another breach in Effective from the previous inspection, in relation to staff training will not be reviewed fully until the next comprehensive inspection. This means Effective cannot be rated higher than Requires improvement.

The registered manager had deregistered when we inspected but continued to work in the service during a handover period to a new manager. Since this inspection, this has been corrected and the registered manager was again in this role. 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. Since the last inspection, changes had been made to the senior management of the service. There was a new director of compliance and a new administrator. Some roles were still being defined as two staff were leaving and supporting new staff to understand and take over their responsibilities.

No risks, concerns or significant improvement were identified in the remaining Key Question of the service being Caring through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

The Oasis is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The Oasis accommodates up to 35 older people who may be living with dementia. On the day we inspected, 29 people were living at the service.

We found positive steps had been taken to make improvements since our inspection in April 2018 but not all aspects had been fully implemented yet. The service was in a process of review and restructure which impacted on meeting all the issues fully. A new management structure had been brought in which was still in process of being finalised. Two staff were leaving, new ones had been employed and others were waiting to be appointed. This meant we could not fully assess that the issues from the previous inspection had been addressed.

We found some people’s risks continued to not always be assessed and mitigated. Progress had again been made but these changes were not showing on all people’s records.

People now lived in a service where infection control was being managed effectively, as well as fire safety and the administration of people’s medicines.

The systems in relation to how people’s capacity was assessed and recorded were now in place. People who may deprived of their liberty to keep them safe could be assured this was being appropriately managed. Staff were clear then on what people could do for themselves and when they were acting in people’s best interests.

People’s records demonstrated more clearly how staff were ensuring their care was personalised. People’s personal history had been combined into their care plan. Also, people could take part in a range of activity in line with their ability and needs. This meant people could be kept active in mind and body.

We found a breach of the Regulations. You can see at the back of the full report the action we have told the provider to take. We have recommended the provider reviews their care plan auditing process to ensure that all gaps in people’s records are identified and acted on.

These findings should be read in conjunction with our previous inspection that can be found at https://www.cqc.org.uk/location/1-3518306155

Since February 2017, we have received two whistle blower concerns and three complaints. These raised concerns about the equipment being used in the service, one concern about end of life care, concerns about how staff were recording when they administered medicines and the training of new staff. A whistle blower also raised a concern about the staffing, language ability of staff, medicines being given to people without their consent and alarm mats being in use that are causing people to fall as they slipped under foot when they stood on them. These were raised with the provider who responded. However, we also checked these concerns on this inspection. We found concerns in some areas which are summarised below.

The Oasis is registered for 35 older people who may be living with dementia. On the days we were at the service, 31 people were living there. 19 people were living with dementia or noted to have a level of “confusion” and/or short term memory loss. Staff did not offer nursing care; nursing care is provided by the community nursing team.

The Oasis is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

A registered manager was employed to oversee the running of the service. 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. One of the providers also managed aspects of the service. A deputy manager oversaw much of the administration and shift leads managed the day to day running of the shift, speaking to GPs, medicine administration and organising staff. Different staff had lead roles such as in end of life care and infection control.

The governance framework did not ensure responsibilities among staff were clear. Throughout this inspection, we found staff roles were poorly defined. Records about the same issue were held by different staff in different parts of the service. The registered manager and registered providers deferred accountability to each other rather than remaining accountable or at least knowledgeable about how that area of running the service was being maintained.

The registered manager and provider failed to have effective quality assurance systems that ensured all areas of the service were safe and of the quality expected. For example, during the inspection we identified a number of areas that were not being monitored. This included infection control; ensuring people had the required risk assessments in place; staff were suitably trained, supported and informed and people’s records reflected their choice. Where audits were completed, these did not evidence what action had been taken to resolve the issues identified.

People were not always protected by safe infection control and food handling practices. We witnessed poor infection control practices. All staff had not been appropriately trained to keep people safe. The laundry was not being managed safely. Chemicals were not being handled in line with legislation. We advised Environmental Health of these concerns.

People were not always ensured any risks would be identified or addressed. People at risk of choking, high or low blood sugar (diabetes), and/or due to the use of blood thinning drugs did not have their risks assessed. People’s care plans only contained minimal information and were the same for each person. They lacked personalised details about how the person required their care to be delivered. Examples of missing essential information included how staff supported people living with dementia, diabetes and having a catheter in situ.

People and their families gave positive feedback about the quality of the food and people at risk were identified, assessed and had their needs met. People told us they were no longer being asked what they want to eat and the menu showed one choice of meal. People confirmed they could ask for other choices which would be given them. The provider, when told of this advised, everyone should be being asked what they wanted to eat before each meal. They acted to reinstate this.

People had activities provided but we observed times during the inspection when people sat in the lounge, mainly asleep, for large parts of their day with little or no stimulation from staff.

People had their faith and cultural needs met. People’s end of life needs were planned for and the service had achieved accreditation from the local hospice.

The management of medicines was not always in line with current guidance. For example, we found many gaps in the medicine administration records (MARs); handwritten ones did not hold a second staff signature to ensure accuracy. Codes that told us why a person had not been given their medicine were not consistently used. People said they received their medicine as required.

The Mental Capacity Act 2005 (MCA) was not fully understood by staff we spoke with. People received medicines covertly. That is, without their knowledge and consent. The service was not demonstrating they had recorded the person’s capacity and this was a best interests decision. This was the same in respect of the use of alarm mats reported to us by the whistle-blower. We discussed consent with staff and observed people receiving support that allowed them time to choose.

People were not ensured to be safe in the event of a fire. We spoke with the fire service who attended during the inspection. This was due to gaps in training staff (at night), the standard of the Personal Emergency Evacuation Plans (PEEPs) and the laundry. The fire service have written to the provider about these issues, emergency lighting and ensuring an upstairs exit, that could pose a fall from height, as the door will release when the fire alarm sounds. The provider has provided further information following the inspection that all staff training in respect of fire safety has now taken place.

All staff were not suitably trained, supervised or checked as competent to carry out their role effectively.

Staff were recruited safely. Staff understood how to recognised abuse and what steps to take to keep people safe. Staff would report any concerns to senior staff and felt action would always be taken. Staffing levels on the day of the inspection were appropriate to people’s assessed needs. All staff we spoke with said there were enough staff on duty at all times to meet the needs of people.

People said their health needs were met and they could see a range of health professionals as needed. People told us the staff were kind, caring and responsive to their needs. People said they felt respected and treated with dignity at all times. Some people said the training of some staff could be improved so all staff were as skilled.

People, families, professionals and staff had opportunities to speak about any complaints, worries and ideas about how the service was being run. The registered manager and provider told us they were looking to improve this.

We found three breaches of Regulations. 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.

We also made a recommendation that the provider uses reputable sources to ensure people living with dementia receive appropriate levels of interaction and stimulation.