Background to this inspection
Updated
17 February 2022
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 Care Act 2014.
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
The inspection was carried out by two inspectors.
Service and service type
Oakwood Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service did not have a manager registered with the Care Quality Commission. There had not been a registered manager employed at the service since March 2021. This means the provider is legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service.
During the inspection-
We spoke with two people who used the service about their experience of the care provided. We spoke with seven members of staff including the provider’s appointed management consultant, deputy manager, nurses, care assistants and the kitchen assistant.
We reviewed a range of records. This included twelve people’s care records and multiple medication records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at training data and fire safety records.
Updated
17 February 2022
About the service
Oakwood Nursing Home is a residential care home providing personal and nursing care to 19 people aged 65 and over at the time of the inspection. The service can support up to 29 people.
The home can accommodate 29 people in shared and single rooms across two floors in one building. The home has shared communal bathrooms. There is a communal lounge, dining area and courtyard garden.
People’s experience of using this service and what we found
The judgement of this service takes into account the previous breaches and rating in each domain.
Risks to people had not been monitored or reduced. At this inspection people were at risk of pressure sores, dehydration, infection, exposure to chemicals and unsafe food safety measures.
Medicine management required improvement. We found a prescribed flammable cream stored incorrectly.
The provider had failed to analyse accidents, incidents or information of concern. When things had gone wrong, preventative measures had not been put in place which led to repeated issues.
The location had inadequate amenities available for people, we found areas of the location to be in a state of disrepair.
People continued to be at risk of falls from height, windows were not consistently restricted. This had also been identified in our previous inspection 28 April 2021.
Care records did not always contain the correct information and people’s choices and beliefs had not been followed.
Staff treated people with dignity and respect. However, the provider’s systems and processes did not always support person centred care and not all risks had been mitigated to ensure people were safe.
The provider had failed to ensure there was adequate oversight of the service. Quality assurance systems and processes did not identify or address issues in the service during this inspection and the previous two inspections.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; however, the policies and systems in the service did not support this practice.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was requires improvement (published 7 July 2021) and there were two breaches of regulation. At this inspection enough improvement had not been made and the provider was still in breach of regulations.
Why we inspected
The inspection was prompted in part due to multiple concerns received about risks to people not being managed safely. A decision was made for us to inspect and examine those risks.
We found the provider had not taken effective actions to mitigate the risks.
The inspection was also prompted in part by notification of a specific incident. Following which a person using the service died. This incident is subject to an investigation. As a result, this inspection did not examine the circumstances of the incident.
The information CQC received about the incident indicated concerns about the management of clinical care.
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.
We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well-led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified breaches in relation to safe care, the premises and oversight of the service at this inspection.
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
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
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.