7 June 2021
During an inspection looking at part of the service
People's experience of using this service and what we found
There were not always enough staff on duty to keep people safe and meet their needs and requests. Staff understood the importance of risk management. However, records to support risk management were not always consistently completed. Systems and processes were ineffective in managing and responding to safeguarding concerns. Incidents were not always reported to CQC when required.
Although some improvements had been sustained since our previous inspection visit, some areas had deteriorated. At the time of the COVID-19 pandemic, the provider's infection prevention and control measures were not effective, so people were not consistently protected from the risks of cross infection. Risk management in relation to the premises was ineffective.
Since our last inspection, staff had not continued to receive updated training and guidance to ensure they could meet people's support needs. People were not effectively supported to maintain their nutrition and hydration needs and access the health care they needed. The culture and practices of the service did not support people to have maximum choice and control of their lives.
People's privacy and dignity was not always respected. The provider did not ensure that people’s care plans were up to date. Staff worked with the same people regularly, so they knew them well. People could engage in some group activities, however, not everyone had enough to do to stimulate and interest them. The environment required improvement to ensure people felt respected and cared for and to help them orientate to their surroundings.
Some staff were seen to be thoughtful and kind, spoke to people with friendliness and humour and took time to acknowledge and encourage people. When people had made decisions about their end of life care, this was documented in their care plan.
The provider had appointed a new manager since our last inspection visit. The new manager was supported by a deputy nurse manager, an operations manager, a facilities and finance manager and the provider. However, immediately following our inspection visit, the new manager and operations manager left their roles. We found the roles of the management team at Oldbury Grange were not clearly defined, to ensure ownership of their responsibilities. Quality assurance procedures were ineffective in ensuring actions were consistently taken to improve the service.
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 November 2018) and there was a breach of regulation 12 safe care and treatment. The provider completed a monthly action plan after the last inspection to show what they would do and by when to improve. At this inspection the provider remained in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: safe care and treatment. We also identified breaches in Regulation 18: staffing, Regulation 17: good governance, a breach of the Regulations 2009, Registration Requirements, Part 4, 12(2) Statement of purpose and a breach of the Regulations 2009, Registration Requirements, Part 4, 18(1) Notification of other Incidents. The service has deteriorated to Inadequate.
Why we inspected
The inspection was prompted in part due to concerns received about infection control procedures and the safety of the premises. We also needed 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 have cancelled the provider's registration.
Follow up
The overall rating for this service following the inspection was ‘Inadequate’ and the service was therefore in ‘special measures’. This meant we kept the service under review.