Archived: Oakwood Residential Home

Updated 12 October 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was completed by 3 inspectors and 2 Experts by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Oakwood Residential Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Oakwood Residential Homes is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. A new manager had been appointed and had been in post 6 weeks. An application to register as manager of the service had not yet been received.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed the information we had received about the service since the last inspection. We sought feedback from the local authority who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 7 people and 14 relatives of people who used the service about their experience of the care provided. We spoke with 12 members of staff including the manager, care staff, kitchen staff, housekeeping and maintenance.

We reviewed a range of records. This included 8 people's care records and multiple medicines records. We looked at 4 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including audits and policies and procedures were reviewed.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

Updated 12 October 2023

About the service

Oakwood Residential Home is a residential care home providing personal care and accommodation for up to 28 people. The service provides support to older people and those who may be living with dementia. At the time of our inspection there were 21 people using the service. Accommodation was spread over two floors accessible via a lift.

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

At this inspection the provider had failed to address the breaches of regulation identified at our previous inspection in August 2022. The provider had submitted an action plan following the last inspection but had failed to make or sustain improvements in these areas.

Systems to oversee the quality and safety of the service were not robust or effective throughout all levels of management. The provider did not maintain effective oversight of the service to support the manager to meet their responsibilities around providing good quality care.

Governance processes and systems had not identified all the concerns we found. Medicines were not being properly and safely managed including controlled drugs. There were omissions and errors, a lack of stock control and monitoring, lack of training and effective auditing. Systems to identify and mitigate risk were not effective. People were at increased risk of harm due to poor infection control procedures. Risks related to the premises were not safely managed, this included risks related to fire safety and Legionella.

The provider did not ensure recruitment checks were carried out in line with the regulations. People were at increased risk of being cared for by staff without the knowledge and skills to fulfil the requirements of their role. Staff did not always receive training or training updates in line with their role. There were significant numbers of staff who required or were overdue updates in key areas relevant to their role, such as medicines; mental capacity; moving and handling; fire; safeguarding adults; first aid, infection control, food hygiene; dementia; end of life care and health and safety.

People's assessments and care plans were not always accurate or complete. People's care was not always personalised. Further work was required to reduce the risk of people experiencing social isolation through personalised activities. The home environment did not reflect dementia friendly best practice to best meet people's needs.

Systems and processes to safeguard people from the risk of abuse were not effective. The provider did not always report allegations of abuse in line with safeguarding requirements. This resulted in an increased risk of harm to people. Lessons were not always learnt when incidents occurred to reduce the risk of re-occurrence.

We found the principles of the Mental Capacity Act 2005 (MCA) were not always followed, for example in relation to the use of bed rails, care and treatment and medicines. 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.

People told us they felt safe. We received mixed feedback from relatives including, "Yes, just about safe. Staff go into [relative’s] room to check them minimally and don’t check regular" and "Yes [relative] is safe from what I’ve seen."

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 1 November 2022) and there were breaches of regulation. 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 the provider remained in breach of regulations.

Why we inspected

This inspection was prompted by a review of the information we held about this service and in part due to concerns received about risk management and staffing. A decision was made for us to inspect and examine those risks.

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 overall rating for the service has changed from requires improvement to inadequate based on the findings of this inspection.

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

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

Enforcement

We have identified the provider failed to fully address the action we told them to following our last

Inspection. There were continued breaches in safe care and treatment, staffing and fit and proper persons. We have identified further breaches in relation to person centred care, dignity and respect, need for consent, safeguarding, premises and equipment, good governance and failure to notify at this inspection.

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

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.

Follow up

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.