OLIVE ROW CARE HOME

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

People’s needs had not always been assessed or reviewed. People’s risk assessments and care plans did not reflect peoples’ current needs. There was a lack of managerial and clinical oversight of people losing weight and people’s food and fluid intake. Staff did not always follow best practice guidance for the management skin integrity. Staff did not support people to get out of bed daily. This placed people at increased risk of worsening mobility. People’s care was not routinely monitored to continuously improve it. People’s capacity and ability to consent to care had not always been considered in planning and managing their care.

This service scored 33 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People’s needs had not always been assessed or reviewed. The manager was aware people’s risk assessments and care plans did not reflect peoples’ current needs. The care plans did not provide enough detail to inform staff how to meet people’s needs. The manager was in the process of updating people’s care records, however, they told us this would take a considerable amount of time to complete. We received mixed feedback from people and relatives as to whether they had been involved in the assessment of their care and support needs and care planning. One relative said, “I was not involved in the assessment. [Person] is happy enough she has friends, and the staff are aware of this, and they sit them together.” Another relative said, “The only assessment we have done was financial, we have never sat down to talk.”

Staff did not have all the information they needed to know how to manage people’s needs. Staff did not have the information they required to know how to manage conditions such as chronic obstructive airways disease, mixed dementia, autism, diabetes, falls or high infection risks.

There was no system in place to ensure people’s risks were assessed or reviewed as their needs changed. There was no system to ensure staff had all the information they needed to provide care that met people’s needs.

We received mixed feedback from people and their relatives in relation to the food and drinks provided. Some people told us they were hungry and did not always receive the meal they had asked for. We observed people had missed meals as the staff did not have a reliable system to check everyone had received their meal. Some lunches were served mid-afternoon, leaving a long time since breakfast and a short time to their evening meal at 5pm. People who received their personal care late morning, missed the morning tea round with a snack, and had a long period between breakfast and lunch. People’s care records showed people ate at irregular times. People did not get the opportunity to have three meals a day due to the spacing of the meals. One person told us, and staff they were intolerant to lactose, but staff continued to offer them daily yoghurts. The information provided to staff about people’s diet did not include this intolerance. People did not always receive enough to drink to maintain their health and well-being. Although staff recorded what people had drunk, the electronic care system did not accurately reflect what people had drunk and calculated that people had drunk double the quantity. People were at increased risk of dehydration, urine infections and feeling unwell. Where people were losing weight, they did not have an updated plan of care to manage their weight loss. Staff did not record they had provided additional nutrition or fortified meals. Staff reviewed and dressed people’s wounds at irregular intervals. This did not provide the consistency required to aid wound healing in line with best practice and placed people at risk of further skin deterioration.

Staff did not have all the information required to ensure people always received the food and drink that met their needs, including allergies. For example, staff provided sugary foods to people living with diabetes controlled with a low sugar diet.

There was a lack of managerial and clinical oversight of people losing weight and people’s food and fluid intake. Information provided to staff about people’s dietary needs was not complete as it did not include allergies, intolerance's and dislikes. The management team had identified the electronic system did not accurately calculate the amount people had drunk. They failed to implement an interim system until the issue was rectified. There was no reliable system of clinical oversight of wound management. There was a document to keep track of people’s wounds, however, this did not include all the wounds people had that required a dressing. There was no detailed description of the wound, its healing progress, or the frequency required for the change of dressings in line with best practice guidance.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

Most people and relatives we spoke with told us they could access healthcare professionals when needed, such as their GP. One person told inspectors they had asked staff to see their GP, however, this was not facilitated. A relative said, “I don’t think the staff always pick up on when [person] is poorly. I knew there was something wrong and I told the staff, but they did nothing, then I went in again a couple of days later and he had a water infection.” A person told us, “I had a temperature, they [staff] rang 111 straight away.” People were cared for in bed daily when they had the ability to sit in a chair. Staff did not support people to get out of bed daily. This placed people at increased risk of worsening mobility. One person told us they had been in bed so long, that when they do get the chance to get out of bed, they get tired quickly and their back feels weaker. Another person told us they would need physiotherapy to get strong enough to use their wheelchair again.

The manager told us they had identified three people they wanted to refer to the community psychiatric team, but they had failed to make the correct referrals. Records showed the manager had asked a visiting community psychiatric nurse to review these people and had been advised they need to go through the proper referral route. This had caused a delay in referring people to the health professionals they needed. Staff did not always understand what people were saying to them. Staff did not have the training, knowledge or information to provide people with the care that kept people mobile, hydrated and healthy. Staff did not always recognise when people’s health was deteriorating. Staff were not able to meet people’s needs as they did not have all the information they needed about people’s conditions or plans of care. The provider had implemented additional training for staff to monitor hydration more closely and how to recognise deterioration in health. There was no oversight of people’s mobility.

There was no system in place to ensure all people received the care that met their needs, as the staff did not have the information about people's needs, risk assessments and care plans did not reflect people's current needs and people were not facilitated to live healthier lives as they were not facilitated to mobilise daily. The management did not have the information they needed to make the referrals to other health professionals; this had caused a delay in referrals. There was no reliable clinical or managerial oversight of people’s care to ensure people were receiving the care that met their needs and correlated with their plan of care. There was a lack of insight into the actual care people received. Care plans were not detailed and feedback from a visiting healthcare professional demonstrated there was a problem with communication between staff and people. The visiting health professional said, “There is a language barrier. I have spoken to staff and they don’t understand what I’m saying.”

People’s care was not routinely monitored to continuously improve it. People experienced signs of dehydration, hunger, sore skin and constipation. One person complained of constant and all over pain. They had not been assessed for their discomfort or been given regular pain relief. People who could express their concerns told staff when they felt unwell. However, not all staff responded appropriately. For example, one person told night staff they felt overly hot, restless and unwell. The night staff had not shared this with the day staff, or taken their clinical observations to check their health status. One person who required a low sugar diet to control their diabetes was regularly given sugary foods by staff. In February 2024 the district nurse team detected their blood glucose levels were higher than they should have been. They reminded staff not to give sugary foods to control their diabetes, however, records show they were continually given marmalade, jam, cakes, biscuits and puddings in February and March 2024. The information from the incident of high blood glucose had not prompted improvements to be made. This person remained at high risk of uncontrolled diabetes due to the lack of monitoring and implementation and shared learning about their diet.

Staff did not have the tools or experience to assess people for their levels of pain or deterioration in health. Care staff did not understand when to inform nursing or senior staff about changes in people’s behaviour or appearance.

There was a lack of management and clinical oversight of people’s health conditions and well-being. There was no reliable system to check people had received their care in a timely way. There was no reliable system to check people had their food, fluids, bowels and skin monitored, or any actions taken to prevent deterioration. There was no reliable system for staff to share their concerns about people’s pain, behaviour or appearance which could indicate a deterioration in their health.

People’s views and wishes had not consistently been considered to plan their care. People’s capacity and ability to consent to care had not always been considered in planning and managing their care. People told us staff asked for their consent prior to supporting them. A person told us, “They [staff] say we are going to give you a wash, if I don’t want them too, I will say that.”

People’s care plans stated staff could act in their best interests where people were unable to make decisions about their care. However, there were no mental capacity assessments for each of the expected circumstances, or a record of a best interest meeting having been held to state what care could be given in their best interest. People were at risk of receiving care from staff that was not in their best interest.

The provider failed to have systems to record and maintain records of Deprivation of Liberty Safeguards (DoLS) applications. The information held about peoples DoLS applications were incomplete, inaccurate and had not always been made appropriately. For example, one person’s DoLS application had been sent to the wrong local authority; this had not been identified for 8 months. People were at risk of having their liberty deprived without the appropriate authority in place.