Archived: Oakford Manor Nursing Home

Updated 5 August 2021

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

This inspection was carried out by two inspectors.

Service and service type

Oakford Manor 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. The previous manager had not registered with CQC. The service has been without a registered manager since January 2020. A registered manager and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was announced to the provider by email, the inspection team arrived at the home simultaneously as the email arrived. The announcing email was sent to reassure the provider of the COVID-19 testing completed that day by the inspection team and that inspectors would wear PPE throughout the inspection visit.

What we did before the inspection

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. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with three people who used the service and five relatives about their experience of the care provided. We spoke with 12 members of staff including the compliance manager, area manager, manager, administrator, and support workers.

We reviewed a range of records. This included eight people’s care records and multiple medication records. We looked at four 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, rota’s and quality assurance records. We spoke with professionals who regularly visit the service.

Updated 5 August 2021

About the service

Oakford Manor Nursing Home is a care home providing personal and nursing care to 23 people aged 65 and over at the time of the inspection. The service is registered to support up to 50 people, however this includes eight ‘companion rooms’ which were not used. Each person living at the service has their own bedroom. The building is set over two floors, during inspection the ground floor was used for people receiving nursing and personal care and the first floor was used for people who received personal care.

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

There were widespread and significant shortfalls in the way the service was led by the provider. The delivery of high-quality care was not assured by the leadership or governance in the home. Audit systems failed to highlight the concerns we found during the inspection. There continued to be a lack of stable management in the home. Staff told us they felt managers were unsupported in their role by the provider.

National guidance in relation to new admissions during COVID-19 was not followed. This placed people and staff at increased risk. Risk assessments were in place but did not always cover all relevant risks to people’s health and safety. Accidents and incidents were reported to the relevant agencies; however, little action was taken by the provider to learn from these. The provider did not ensure there were always enough suitably qualified staff to give people the support they needed.

Records did not always show that care was delivered in a way that responded to people’s needs. There was a complaints policy and procedure in place which people and their relatives had access to. Some language used in care plans was not respectful. The provider responded immediately and assured us action would be taken to address this.

Staff were observed to be kind and caring with close bonds with people. People were involved in care planning.

Most 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; the policies and systems in the service generally supported this practice. The provider did not always recognise their responsibility in ensuring people were protected under the Mental Capacity Act (MCA), this was addressed after our inspection.

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 inadequate (published 23 September 2020) and there were multiple breaches of regulation. This resulted in a warning notice for the service. We returned to the service to follow up the breaches of regulation and see if sufficient improvement had been made. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

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

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 safety, governance, staffing levels, staff training, safeguarding people from abuse and meeting legal requirements.

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 continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We will request an action plan for 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.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service remains 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 of 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.