Oak Springs Care Home

Updated 25 October 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 27 September and 1 October, 2018 and was unannounced.

The inspection team consisted of one adult social care inspector, one inspection manager, an ‘Expert by Experience’ and a ‘Specialist Advisor’. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service and a Specialist Advisor is a person who has professional experience and knowledge of the care which is being provided.

Prior to the inspection we reviewed the information we held in relation to Oak Springs. This included the statutory notifications sent to us by the registered provider about incidents and events that had occurred at the service. A notification is information about important events which the service is required to send to us by law. We also contacted the Local Authority and the local Clinical Commissioning Group to get their opinions of the service.

A Provider Information Return (PIR) was also reviewed prior to the inspection. This is the form that asks the provider to give some key information in relation to the service, what the service does well and what improvements need to be made. We used this information to formulate a planning tool, this helped us to identify key areas we needed to focus on during the inspection.

During the inspection we spoke with the registered manager, four members of staff, two people who lived at the home, six visiting relatives, one activities co-ordinator, the head chef and one external professional.

We looked at the care files of five people receiving support from Oak Springs, four staff recruitment files, policies and procedures, medicine administration processes, compliments and complaints, and other records relevant to the quality monitoring of the service.

We undertook general observations of the home over the course of the two days, including the general environment, décor and furnishings, bedrooms and bathrooms of some of the people who lived at Oak Springs, lounge and dining areas.

In addition, a Short Observational Framework for Inspection (SOFI) tool was used. SOFI tool provides a framework to enhance observations during the inspection; it is a way of observing the care and support which is provided and helps to capture the experiences of people who live at the home who could not express their experiences for themselves.

Updated 25 October 2018

This inspection took place on 27 September and 1 October 2018 and was unannounced.

Oak Springs is a residential ‘care home’ which provides accommodation and personal care for up to 74 older people, including people living with dementia. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Care is provided over three floors. The service can provide en-suite accommodation. At the time of the inspection 69 people were living at Oak Springs Care Home.

At the time of the inspection there was a registered manager in post. 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. During the inspection we found the registered manager to be open, transparent and receptive to the feedback provided.

At the last inspection which took place in August 2017 we identified breaches of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Oak Springs was awarded an overall rating of ‘Requires Improvement’. Following the inspection, we asked the registered provider to complete an action plan to tell us what changes they would make and by when. During this inspection, we looked to see if the registered provider had made the necessary improvements.

At the last inspection, we found the registered provider was in breach of regulation in relation to ‘safe care and treatment’ people received. Medication management systems were not followed and the health and safety of people living in the home was being compromised. During this inspection we found that the registered provider was no longer in breach of this regulation in relation to ‘Safe care and treatment’.

At the last inspection, we found the registered provider was in breach of regulation in relation to ‘Good Governance’. The systems which were in place did not effectively monitor and assess the quality and safety of care people received. During this inspection we looked at the governance systems, audits and checks which were in place and found that improvements had been made. Although the registered provider was no longer in breach of regulation in relation to ‘Good governance’ further developments could be made in relation to this area of care.

We have recommended that the registered provider reviews some of the quality assurance systems to further improve the quality and safety of care being provided.

At the last inspection we identified concerns in relation to staffing levels and the deployment of staff. During this inspection the registered manager told us that a monthly dependency assessment tool was completed and analysed. The dependency tool helped to review the dependency support needs of the people who lived at Oak Springs in relation to the levels of staff. Staffing levels were safely managed and people received the level of care and support that was required.

Recruitment was safely managed. People who were employed had undergone the necessary recruitment checks. Pre-employment and Disclosure Barring System checks (DBS) were carried out and appropriate references were sought prior to employment commencing.

Risk assessments were in place for people who lived at Oak Springs. Risk assessments were tailored around the needs of the person, support measures were in place to mitigate risks and assessments were regularly reviewed and updated. Staff were familiar with people’s risks; they received daily updates on people’s health and well-being and if their circumstances had changed.

People were protected from harm and abuse. Staff were familiar with safeguarding and whistleblowing procedures and told us what concerns they would report, who they would report their concerns to and the importance of complying with safeguarding and whistleblowing policies the registered provider had in place. Safeguarding referrals were appropriately submitted to the local authorities and CQC as required.

Accidents and incidents were routinely recorded and analysed. There was an accident and incident reporting policy in place and staff routinely completed accident and incident documentation. The registered manager analysed monthly accident and incidents reports and established trends that were emerging as a measure of mitigating risk.

We found the home to be clean, hygienic and odour free. Communal areas, toilets, bathrooms and bedrooms were well maintained. Infection prevention control measures were in place and staff had access to personnel protective equipment (PPE) such as gloves, aprons and sanitizing gels.

We reviewed health and safety audit tools. Weekly, monthly and annual audits and checks were completed to help monitor and assess the quality and safety of the home. Such audits/checks ensured that health and safety standards were maintained and the safety of people living at Oak Springs was not compromised. Regulatory compliance checks were also completed; compliance certificates were checked and in place during the inspection.

The registered provider was complying with the principles of the Mental Capacity Act, (MCA) 2005. Consent to care and treatment was gained in line with the MCA. People’s capacity was assessed from the outset and records contained the relevant information in relation to the persons capacity. Appropriate Deprivation of Liberty Safeguards (DoLS) were submitted to the local authority and records contained relevant ‘best interest’ information and restrictions which were in place.

Staff received regular supervision and told us they received support on a day to day basis. Staff were supported with training, learning and development opportunities. Training statistics were reviewed by the registered manager and there was a commitment to provide training to staff that helped to enhance their skills, competencies and abilities.

People’s nutrition and hydration support needs were effectively managed. People were regularly assessed and measures were in place to monitor and mitigate risk. We found that appropriate referrals were made to external healthcare professionals and any guidance which was provided was incorporated within care plans.

Reasonable adaptations and adjustments had been made to the environment to support people who had limited mobility and were living with dementia. There had been noticeable improvements to the environment and the registered manager was committed to enriching the lives of people who lived at Oak Springs.

People were supported with ‘choice’ in relation to the food that was offered. We received positive feedback about the quality and standard of food and the registered manager ensured that people were given the opportunity to share their views and thoughts about the food they received. ‘Meal time experience’ surveys helped the registered manager to create menu’s around the suggestions, preferences, likes and dislikes of people living in the home.

We observed people being treated with dignity and respect. Staff provided kind, caring and compassionate support in a genuine and sincere manner. People’s independence was promoted and staff were committed to providing care and support that was tailored around their needs.

Confidential information was securely stored and protected in line with General Data Protection Regulation (GDPR). This meant that people’s sensitive and personal information was not unnecessarily shared with others.

A person-centred approach to care was evident. Records were tailored around the needs of the person and staff were familiar with the likes, dislikes, preferences and wishes of people they supported.

The registered provider had a complaints policy in place. People and relatives were familiar with the complaints process and told us they would feel comfortable making a complaint if required. A complaints folder had been created; the registered manager regularly reviewed the variety of complaints submitted to establish trends and ensure lessons could be learnt.

People had the opportunity to engage and participate in a range of different activities arranged by the dedicated activities co-ordinators. We received positive feedback about the different activities that were taking place. Activities were stimulating and were tailored around the suggestions and interests of the people who lived at Oak Springs.

People were sensitively supported with end of life wishes and preferences. Records we checked contained end of life documentation (where required) and staff were familiar with any specialist support that was needed

.

Systems were in place to gather feedback regarding the provision of care that was delivered. People, staff, relatives and external professionals were encouraged to share their views, opinions and thoughts around the quality and safety of care people received. This enabled the registered manager to identify areas of strength but also areas that needed further attention.

The registered manager was aware of their regulatory responsibilities. The registered manager notified CQC of all events and incidents that occurred in the home in accordance with statutory requirements. Ratings from the last inspection were displayed within the home as required.