Oak House

About the service: Oak House is a nursing and residential care home it is registered to provide nursing and personal care for up to 120 people aged 65 and over on three floors. At the time of our inspection the service was providing personal and nursing care to 109 people.

People’s experience of using this service:

Medicines were not always being managed in line with best practice.

Recording of people’s care requirements was not always accurate, complete and contemporaneous in relation to care delivery.

Systems for governance did not highlight the issues we found in relation to documentation and medicines.

At the time of our inspection the service was in the process of registering a new manager to manage the service.

Staff were safely recruited and received the training they needed to undertake their role. Supervisions were not always carried out to ensure staff were supported in their role.

Care records contained information about people's needs and risks. Preferences and choices were

considered and reflected within records.

The service had appropriate checks and maintenance to ensure the service and equipment was safe for people living at the service.

There was a wide range of opportunities for people to engage in activities and follow hobbies and interests.

People were very positive about the staff and told us that their privacy and dignity was promoted.

The service had good community links and had a number of initiatives with local churches and schools.

Rating at last inspection: At the last inspection the service was rated Good (the report was published on 17 August 2016). Following this inspection, we found the service requires improvement.

Why we inspected: This was a planned inspection based on the rating at the last inspection.

Follow up: We will continue to monitor information and intelligence we receive

about the service to ensure good quality is provided to people. We will return to re-inspect in line with our inspection timescales for Requires Improvement services.

We identified four breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 relating to safe care and treatment, safeguarding service users from abuse and improper treatment, staffing and good governance. Details of action we have asked the provider to take can be found at the end of this report.

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

The registered manager has been in post since September 2015 but was not available during our visit. 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 and associated Regulations about how the service is run.

The location was last inspected on 5 September 2014, where we found they were meeting the standards on the outcomes inspected. This is the first inspection of the location under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People felt staff were caring and looked after them well. Comments included, “Yes they go out of their way for you” and “They handle you in a kind way and they know you.” We saw a number of good examples of how staff showed concern for people’s wellbeing in a caring and meaningful way. People were supported when making decisions about end of life care.

People felt staff were skilled to provide care, treatment and support to them. Staff received appropriated induction; training and supervision. They spoke highly about the support they received from management. Care records showed staff sought consent from people before care was delivered. People’s nutritional needs were met and the service ensured they were supported to maintain good health.

People said they felt safe when care was being delivered. Staff knew how to protect people from abuse and avoidable harm. People were protected from unsafe care because there were sufficient staffing levels to meet their individual needs.

People said the care they received was specific to their needs. Care plans showed how people would like to received care, support and treatment. Daily handovers for staff provided by team leaders ensured the care being given was responsive to people’s needs. .

People felt the service was well-led. For example, one person commented, “The senior staff and management I think are of high quality and everything runs smoothly.” Management conducted staff meetings to ensure people’s welfare and safety was protected, staff understood their responsibilities and best practice was shared. The service had established effective quality assurance systems to assess monitor and improve the quality and safety of the service it provided.

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well-led?

Below is a summary of what we found. The detailed evidence supporting our summary can be read in our full report.

Is the service safe?

We found the service was safe.

During our visit on 12 June 2014, we found daily records such as fluid and food intake charts, were not kept securely; peoples' relatives told us they were not aware they could have access to care records and for those who did; found some of the information recorded was not accurate. We judged this to have a moderate impact on people who used the service. We asked the provider to send us an action plan by 30 July 2014 telling us how they intended to achieve compliance. We received an action plan from Oak House dated 15 July 2014. This provided details of the action taken to achieve compliance.

When we re-visited the service, robust systems were in place to assess, monitor and review whether agency and permanent staff were competent to carry out their job roles and had relevant information to enable them to be aware of peoples' care needs. This meant people's welfare and safety were protected. A review of the computer based tracker dated September 2014 showed all care plans had been audited. We reviewed 10 care plans across the three units on the second floor and saw the information recorded was accurate and reflected people's care needs. This showed there were clear systems in place to ensure care records were factual and accurate and ensured people were protected from unsafe and inappropriate care.

People's daily records were now kept securely in the main office. This meant person appropriate action was taken to secure records. The regional director told us they were awaiting arrival of secure cabinets that had been ordered. A review of the 'audit action plan spread sheet' evidenced dates the cabinets were ordered and when staff had chased the suppliers for a delivery date.

Is the service well-led?

We found the service was well-led.

During our visit on 12 June 2014, we found the service had developed new systems to assess and monitor the quality of service provided. However it was too early to judge whether the systems in place were robust enough to analyse and identify themes or demonstrate improvements in the provision of care on the second floor. We judged this to have a moderate impact on people who used the service. We asked the provider to send us an action plan by 30 July 2014 telling us how they intended to achieve compliance. We received an action plan from Oak House dated 15 July 2014. This provided details of the action taken to achieve compliance.

During this visit we found the service had robust systems in place to assess, monitor and review the quality of service provision. We saw various audits undertaken such as, complaints, medication, activities and quality assurance. These showed any actions identified, dates for completion, review dates and updates of what work had been completed.

During our visit on 12 June 2014, we saw 70-80% of the care plans had been updated. During this visit we saw all care plans had been audited. We reviewed 10 computer based care plans across all three units and saw the information recorded was factual and up to date. This meant the service had effective systems in place to ensure all care records were audited and appropriate action was taken when any areas of concern were identified.

On this visit we were able to review the induction programme for agency and permanent staff members. We saw the induction programme was very detailed and showed how new staff were being orientated into the home. We saw details of the experienced staff members they shadowed, the procedures new staff had followed to help them become familiar with the working environment and what statutory and mandatory training they had undertaken. For example, one staff member demonstrated they could competently perform a task without supervision in the area of waste management. This was signed and dated by the manager who had undertaken the assessment. This showed the service had effective systems in place to assess and monitor whether agency and permanent staff were competent in carrying out their job roles.

We saw activities were in place for people who were unable to join in regular activities organised by the service. 'The quality of life record' showed the name of the person involved in the activity, the type of activity they participated in and the time spent. In one record dated 29 August 2014 we saw a staff member spent time talking and listening to a person's favourite selection of music. This demonstrated the service ensured it catered to the social well-being of everyone in the home.

Peoples' representatives were able to feedback what was working well and what required further improvements. For example, with what had worked well. We read comments such as, 'Excellent care, rooms always clean and smell fresh & 'carers are always friendly & staff have a genuine smile' and 'You all take excellent care of my Mum & I'm greeted with a smile.' In relation to what had not worked well we read comments such as 'Spend more one to one time with my Dad and improve the quality of pureed meals' and 'Mum's clothes sometimes go astray despite being labelled.' The service provided a detailed response summarising actions that had been undertaken in response to the feedback received. This showed the service asked for the views of peoples' representatives and they were acted upon.

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well-led?

Below is a summary of what we found. The detailed evidence supporting our summary can be read in our full report.

Is the service safe?

The service is safe.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The manager described how they were working with the Supervisory body in order to manage DoLS applications and with the relevant Section12 mental Health doctor for issues pertaining to capacity. There have been a number of both urgent and standard authorisation requests and relevant paperwork was noted for each. We found this to be in line with the legislation.

During this inspection we observed medication rounds were undertaken by nurses wearing red tabards with 'do not disturb' signage written clearly on them. This alerted others to the importance of limiting disturbances and protected the welfare and safety of people.

Staff members were observed to be present in lounge areas throughout the day and communicated with one another when they were leaving the area. This ensured people's welfare and safety.

Is the service is effective?

The service is effective.

On this inspection we reviewed nine care plans across the dementia units on the second floor. We spoke with six staff, two relatives and one person. Numerous examples were noted in observations of direct care, when people were asked questions about their daily routines and meal preferences. We heard staff asking people questions such as, 'Which one of these would you like to eat /drink?' and 'Would you like to wear an apron to protect your clothing?' Throughout the day we observed staff asking open and closed questions about all daily living skills. This demonstrated in many areas of decision making, capacity was being assumed, in line with legal requirements.

The units had a number of staff and people from different minority ethnic backgrounds. The home had introduced a number of practices to try and make the care home more reflective of the diverse backgrounds. In one care plan we saw a person was a Punjabi speaker. Care records showed family members had been asked to assist with the making of prompt cards in the dialect of Punjabi which the person understood. In another care plan, we noted an individual was from an African Caribbean heritage. The care records showed communication between the home and the person's family members and reflected partnership work to ensure the person's care and well-being. An example of this was a request had been made to get the person ready particularly early one morning to enable family members to take them to church. This meant the service made reasonable adjustments to reflect people's needs, values and diversity.

Is it caring?

The service is caring.

We observed staff giving people positive validation and making use of re-direction techniques. For example people were being left and then asked again if they would like something. Lots of positive tactile interactions were also observed, such as staff and people hugging one another or dancing with one another. This ensured people's welfare, safety and consistency of care. One person told us, 'I have never been so happy. Staff are very good. They take care of me very well.'

Is it responsive?

The service is responsive.

People's relatives spoke positively about their family members' named nurses and keyworkers. They told us staff knew people's care needs. We heard comments such as, 'The named nurse knows X's needs and I am happy with the care they provide' and the staff member 'is very good with X and knows what they like and dislike. I am confident with the care X receives.' This meant people could be confident they would receive care, treatment and support from staff who knew their care needs.

Is it well-led?

The service is well-led.

The home had structured social activities that catered for the needs of all the people on the second floor. A new computer care plan system was installed in the home May 10 2014. New systems were developed to enable staff (new and agency workers) to become familiar with the people they provided care for; treatment and support were now available on the second floor. Mental capacity assessments and Best Interest meetings were carried out to determine whether people had the capacity to make specific decisions. We saw they looked at the least restrictive options when decisions were made. Staff we spoke with told us they were positive about their work. One staff commented, 'I feel listened to and valued. I am confident any ideas that I put forward in regard to care and welfare of the people in this home, will be listened to.' The staff demonstrated values of pride and commitment. This was evident across all the units on the second floor. One person commented, 'The manager seems to have made things better. Everybody seems happier.' This meant people could be confident they would experience effective, safe and appropriate care, treatment and support that met their needs and protected their human rights.

Below is a summary of what we found. The detailed evidence supporting our summary can be read in our full report.

Is the service safe?

We found the service is not safe.

During our inspection on 7 April 2014 we found care audits undertaken were not robust with records being inaccurate and not fit for purpose, non-compliance in this area lasted for a pro-longed period which placed people's welfare and safety at risk. We judged this had a moderate impact on the people who used the service and issued the provider with a warning notice to be compliant by 29 May 2014.

From our visit today, it was clear systems had been put in place to make improvements around records in order to protect the welfare and safety of people using the service. However, as the audits of care plans had not yet been fully completed this meant some people remained at risk of receiving unsafe care, treatment and support.

We were informed that the home was still transferring information from the old computer based system to the new one and 70 to 80 % of the care plans were updated. The care tracker reviewed showed only 23 of 40 care plans had been reviewed and some were only partially updated. This meant people were at risk of receiving unsafe care, treatment and support.

People's daily charts were stored in the lounge area of the home in an open cabinet. We were told by staff that this was for easy access as they were completed regularly throughout the day. We noted access to these records was not restricted and anyone in the lounge area could gain access to these records. Staff told us that usually staff would be around in the lounge to ensure this did not happen. However, we observed short periods throughout the day when no staff were present in the lounge. This meant daily chart records were not kept securely and had the potential of comprising people's confidentiality.The hard copies of people's care plans were stored in the staff office in a lockable filing cabinet. We checked six people's daily charts. These included food and fluid charts, positioning charts, application of topical medication charts (such as creams) and behaviour charts. All the records we viewed were completed at the intervals stated on the charts. We saw these records were in line with what was to be recorded in these people's care plans.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The home had recently submitted 12 applications to their Supervisory Body. We reviewed the applications and found they were completed appropriately. This meant people were deprived of their liberty in order to maintain their safety and wellbeing. This was done in the least restrictive way and in people's best interest.

Is it well-led?

During inspection on 7 April 2014 people we spoke with were positive about the improvements made since the arrival of the new home manager. However, we found there was no formal induction programme for new staff and agency workers. New systems introduced to support agency staff to enable them be familiar with the people they would be providing care to; review people's care needs and provide social activities for people who were bed bound were not implemented on the second floor. There were no systems to monitor how effective the training staff received had been or what further training was required to support them. The minutes of relatives' meetings seen were not accurate as they failed to record the feedback given by those in attendance. We judged this had a moderate impact on the people who used the service and issued the provider with a warning notice to be compliant by 29 May 2014.

From our inspection today we found the home was continuing to implement the new care plans for all the people living in the home, with a new manager taking the lead. It is too early to make a judgement about the effectiveness of the new system and how well it is led.

Staff we interviewed confirmed the manager carried out daily checks, these have included evening and night time visits. They said that the manager is very approachable and all staff spoken with told us that they would feel comfortable going to the manager if they had any issues. They also said that it was good that the senior staff, unit managers and the manager helped out with personal care when needed.

We spoke with three relatives and heard various comments such as, 'There is room for improvement, familiarity with residents should be the aim, there is a lot of agency staff', 'The new manager is good, and hopefully they will make a lot of improvements. I still don't think there is enough staff' and 'On a management level I have a lot of respect for the manager. Sometimes I don't think my concerns are heard however, I think the manager is doing their best and changes won't happen overnight.' We relayed their comments to the regional manager who stated there were enough staff on duty throughout the shifts however, they would look into this further how they could improve the visibility of staff.

The manager informed us on the second floor 70-80% of the care plans had been updated and care plans were now maintained electronically. The hardcopies were printed off when completed or updated and given to people or their representatives to sign. The care plan tracker given to us showed 23 of 40 care plans were updated and some of those were only partially updated. The manager stated they have been auditing two or three care plans a day along with the clinical audit team who have been working at the home. We reviewed two completed audit forms. This had the names of the people they related to, the date the audit was undertaken and the name of the person who conducted it. The audit covered the areas of care on the computer based care plan. For example, activities, communication, eating and drinking, administration, mental capacity. It then captured what actions were needed to ensure that information on care plans were accurate.

The manager told us the computer care plan system had a 'care plan tracker'. This helped the service to rate care plans with the use of a traffic light system. For example, Green-ok, Amber-some actions needed and Red for not yet completed. Once rated a list of actions is devised to bring the file up to a Green standard. The action plans contained dates for the action to be taken and these are passed over to the unit managers to action. Care plans would then be re-audited to ensure that actions are completed. We looked at the 'care plan tracker' and noted 'safety' was indicated as an area of care however, we could not see where this was covered on the completed audit forms and what it related to.

The manager told us they now had a formal induction programme for new staff. We reviewed the induction programmes for three new staff who joined the home on 9 June 2014. The programme was very detailed and outlined orientation to the home with new staff being allocated to a unit to shadow staff, how staff can become familiar with the environment they worked and statutory and mandatory training requirements for staff. We noted staff had to produce evidence to demonstrate their competency to carry out their job roles within three months. We were not able to judge whether the new induction programme was effective as it had only just come into effect.

Below is a summary of what we found. The summary is based on observations during the inspection, speaking with people using the service, the staff supporting them and looking at records.

The detailed evidence supporting our summary can be read in our full report.

Is the service safe?

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The home had recently submitted one application to their Supervisory Body. We found this to be in line with DoLS legislation.

All the units on the second floor were fully staffed. The unit manager for the second floor confirmed the roster has changed significantly and there had been recruitment drives to ensure there were enough qualified, skilled and experienced staff to meet people's needs. Where there was shortfall in hours, the home had robust system to ensure arrangements for agency cover was made.

A senior member of staff told us there were discrepancies with care plans on the second floor in general. This was due to transitions between systems and care plans not being fully integrated and not all staff members were confident in using the current system. We observed this in the some of the care plans we reviewed and when requesting assistance from staff in order to find information on the computer based care plan. Staff member's inability to confidently use and access computer based care plans placed people's health, welfare and safety at risk.

We looked at the various assessments undertaken on one person and saw they were assessed as high for a fall risk assessment. This stated that they had to be re-assessed monthly but there were no evidence to show this had been done. It was also recorded the person should have a review of their medication; there was no evidence to show this had been done. This showed there were no clear procedures followed in practice, monitored and reviewed to ensure personalised and medical records were kept and maintained for people who used the service.

We have asked the provider to tell us how they will make improvements in relation to staff members' being competent on how to use the computer based care plan system, and how they will ensure clear procedures are follow in practice, monitored and reviewed to ensure personalised and medical records were kept and maintained for people who used the service.

Is the service effective?

We spoke with seven staff members. The staff members confirmed their attendance at MCA and Deprivation of Liberty Safeguards (DoLS) training. However some staff members were only able to demonstrate a basic understanding of the Act and were not aware of their individual obligations to the legislation as care givers. One staff member told us, 'You can tell if someone has capacity or not.' This showed staff members did not understand their legal obligations to the legislation as care givers.

On the morning of our inspection we spoke with one member of staff who told they usually worked in another unit but was asked to provide cover due to staff shortage. The staff member told us they were not too familiar with all the people they provided care to. The staff member mistook a senior member of staff (Registered General Nurse) they were working with as carer. We spoke with the home manager about induction for staff and were told this was to be introduced during the week of our inspection.

We found people were supported to be able to eat and drink sufficient amounts to meet their needs. Throughout the units, tables were observed as being decorated with table cloths, jugs of water and squash, and with vases of flowers. This was conducive to a pleasant eating environment. Another person commented, 'Staff know my food preferences, I am never hungry.' This showed people were provided with a choice of suitable and nutritious food and drink.

We have asked the provider to tell us how they will make improvements and meet the requirements of the law in relation to effectiveness of staff training and induction programme for agency workers, new staff and staff working on units they are not familiar with.

Is it caring?

A relative told us that since the arrival of the new home manager, 'Things are much better.' Another two relatives told us they felt their family members were well cared for and the communication was good and generally things were 'Better than previously. We spoke to a health professional who supported this. They complimented the new regime at the home and told us that good partnership working with other professionals and staff had enabled one of the people they supported to remain in the home. This showed there was continuity of care, treatment and support as a result of effective communication between all those who provided it.

Is it responsive?

We found significant improvements with the care being delivered. For example, care was not rushed. One person told us, 'All I have to do is press my bell and they come to look after me promptly. This meant the service responded promptly to people's immediate needs.

Is it well-led?

There were a number of social activities for people in all three units. For those who chose not to participate we observed staff in the dining areas having time to interact with them.

People talked positively about the improvements that had been made since the arrival of the new home manager. Relatives stated there were lot of problems previously that they were very concerned about. However, since the arrival of the new manager things were, 'So far so good', 'Improving, particularly the staffing.' This was supported by the staff we spoke with. One staff member stated the change in management had made a significant difference and staff felt that morale was much higher and they were supported. One person commented, 'Seems to be run well.'

We reviewed minutes of relatives meetings for the ground and first floor held in February 2014. The minutes seen were not accurate as they failed to record the feedback given by those in attendance. One relative we spoke with whose family member resides on the first floor expressed their disappointment that this had still occurred after it was highlighted in our last inspection report. This meant the service did not actively seek and record feedback from people or those who represented them.

We have asked the provider to tell us how they will make improvements and meet the requirements of the law in relation to actively seeking and recording feedback from people or those who represent them.

One person told us, 'They (staff) are very busy, you only see them if you want something doing.' This meant the social well-being of people who remained in their bedrooms, was not being met.

We observed a person on a pureed diet waited 25 minutes for a member of staff to support them with their meal. This meant people were not being supported to eat or drink in a timely manner. One person's relative talked about the person being on a special diet. They commented, 'The food is very bland here; we have to bring food in just to give it flavour.'

On this inspection we observed staff carried out care, treatment and support with no use of restraint.

One person we spoke with told us, 'Things have changed for the better, and I am now getting washed and dressed early.' However relatives expressed concern about communication and staff awareness and knowledge of the people they cared for.

Relative minutes of meeting notes did not record feedback received from relatives. This meant the service did not appropriately seek feedback from people or those who represented them.

We found some records were more detailed in on the paper care plans than the computer based ones and had the potential of increased risk of unsafe treatment, care and support.

Insufficient staffing and staffing numbers impacted upon the care, treatment and support people received. One person told us they waited an hour for staff to respond, and when staff responded they were told they would have to wait.

A second person said: 'This is the first time I have been up so early. They came and washed me at 9.45am. They have a problem with staffing.' This meant people were not provided with care and assistance within a reasonable time.

A relative told us how their family member liked to eat fish and chips. The relative stated no one talked to them about the person's food preferences. Therefore people's preferences were not consistently being considered when planning meals.

Staff had not received training in the uses of restraint and did not understand that restraint should be used in a way that respected people's dignity and protected their human rights wherever possible.

We found the service did not have effective systems in place to assess and monitor the quality of the service provided. There were no systems in place to appropriately analyse and identify themes or demonstrate improvements in the provision of care

People were supported in promoting their independence. We found uneven standards of care planning which did not support consistent standards of care to people. The service had satisfactory arrangements in place for the control of medicines. Staff received appropriate professional development. Complaints by people were investigated by managers.