Four Oaks Care Home

We found the following examples of good practice.

People were able to spend time seeing and speaking to their visitors in different ways. On-site visits were facilitated by pre-booking and visitors went straight to people’s rooms. They did not interact with any other people at the home and visiting times were not restricted. There were also extensive gardens where visits could take place when the weather allowed.

We observed staff undertaking activities with people and getting ready for their day. We observed how this was done in a safe way for residents and staff, with staff wearing full personal protective equipment (PPE). Stocks of appropriate personal protective equipment (PPE) were well-maintained and staff used and disposed of it correctly. Staff had been trained in infection control practices.

The home monitored the vaccination status of residents and staff and undertook risk assessments when required. The majority of staff and residents had been vaccinated and had received their boosters. COVID-19 testing was undertaken twice weekly by all staff and lateral flow testing was required before each shift. Staff were incentivised to cover, and the use of agency staff was kept to a minimum. We heard how the home had managed to contain Covid-19 to a minimum when staff and two residents had become infected with the virus.

We saw a suite of comprehensive processes and procedures in place to manage risks associated with the Covid-19 pandemic. These included how to care for staff and people using the service who were Covid positive. There were management plans for those people required to self-isolate and additional support available for people who may struggle with isolation.

The last inspection of this service was on 7 and 8 December 2017 where we found breaches in six regulations of the Health and Social Care Act 2008, including concerns that placed people at serious risk of harm. These were in relation to service user safety, falls prevention, mitigating known risks, training of staff, medication, staffing levels and shift management, the monitoring of fluids and the governance and leadership at all levels. Following the inspection, we asked the service to take some immediate action and told the home to produce an action plan to address the issues we had found. We returned to Four Oaks on 19 January 2018 to check that these actions had been taken and the action plan was being implemented.

At the last inspection, we rated the service overall inadequate and the service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this time frame. During this inspection the service demonstrated to us that improvements have made and is no longer rated as inadequate overall or in any key questions. Therefore, this service is now out of Special Measures.

At this inspection, we found significant improvements had been made for the safety and welfare of people living at the home. Further details can be found throughout the body of the report.

Four Oaks is a 'care home'. 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. Four Oaks is a modern purpose-built property which can accommodate up to 62 people in four separate units on two levels. Two units specialise in providing care for people living with dementia. At the time of our inspection there were 59 people living at Four Oaks.

A registered manager was in place. 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.

A new computerised care planning system, person centred system (PCS) had been implanted throughout the home which had largely improved the care planning of each person living at the home. The system was easy to use and staff could record onto the system in real time which had improved daily recording for people. Staff also had access to people’s care and support needs quickly and the system gave prompts to staff to ensure they had completed each task required.

Everyone living at the home said they felt safe. People told us if they had concerns about their safety, then they would have no hesitation is telling someone. Staff we spoke with were aware of their responsibilities in reporting any concerns they had and had completed safeguarding training to enhance their knowledge.

Staffing levels across the home had improved and staff were visible throughout our inspection. All staff we spoke with said there was enough staff on duty. We received mixed responses from people living at the home and relatives with comments being that the home was short staffed at weekends. Agency staff were still used and rotas showed that staffing levels remained consistent across the week. The staff from the agency were regular for consistency.

Staff were recruited safely and received the required checks before employment commenced to ensure they were suitable to work with vulnerable groups.

The management of falls has significantly improved and people who were at high risk of falls were regularly monitored and had appropriate equipment such as falls sensors and mats in place. Staff had received training in falls management and regular reviews of falls looked for themes and patterns with actions identified to assist in preventing future occurrences.

People at risk of choking were regularly assessed and protocols were in place to give advice to staff on suitable consistencies of food and fluids. Staff could clearly describe food and fluid consistency for each person they supported.

People whose behaviour may challenge were risk assessed and some good techniques to reduce agitation were recorded for staff to use. Staff had received training in managing challenging behaviour.

Accidents and incidents were clearly recorded and outcomes shared to prevent future occurrences. Each person had been assessed to ensure they could reach and use their call bell. For those who could not, additional room checks were made to ensure peoples safety.

Medicines were well managed and staff had been appropriately trained to administer medication safely. Improvements had been made to the safe administration of medicines to ensure people who wished to stay in bed, could have their medication at a later time without having to miss any doses. Medicines were regular audited to ensure the safe administration and all medicines were stored securely.

People received an assessment of their needs prior to moving into the home. The assessment then was used to generate care plans using the PCS system. Care plans were generally completed within one to three days of the person moving into the home and where possible, care plans from previous care providers were used while staff got to know the person.

Improvements were needed to enhance people’s dining experience. Although people had choice around meals, they were not planned in advance. Lunch was late on the first date of inspection and items were missed on the food trolley which meant people did not have the item with their meal.

Staff were able to record on the PCS system what people had to eat and drink and hydration checklists were in place to ensure people had at least six to eight glasses of fluids per day. People had clearly recorded in their care plans, their likes and dislikes and their dietary requirements. One person preferred a diet from their own culture and this was observed. The chef met with people to discuss their dietary needs and had details of people’s preferences and requirements including any allergies.

Staff received training to enable them to carry out their job role effectively. The service was in the process of registering with a training consortium to be able to engage in standardised training across the local authority. Additionally, the organisation was working with a training provider to provide diplomas in health and social care. This meant staff could receive training to enhance their knowledge and their role.

The service was working in line with the Mental Capacity Act 2005. People who had their liberty deprived, did so in their best interests. Families were involved in making decisions for their relative and we saw some good examples of best interest’s decisions being taken.

People received appropriate referral and support from health professionals. People told us that they could see a GP when they needed to and we saw that where concerns had been identified in people’s health and wellbeing, referrals were made in a timely manner.

We observed kind and caring interactions from staff to people who lived at the home. We spoke with a relative who had concerns about the home at the last inspection and whom now spoke highly of the service.

People were given choice to how they spent their day and staff were able to describe how best to support each person. Staff told us how they observed people’s dignity and we observed staff to knock on people’s doors and ask for permission to enter. Staff told us that they always explained what they were doing when assisting people with personal care and people told us that staff sought consent from them.

Care planning for people had significantly improved with the implementation of the PCS system. Care plans were person centred, had involved people and captured people’s support needs and preferences. Staff had access to people’s care plans at the touch of the button using the PCS iPod system which meant staff could continually access and update information.

People received support at the end of life and we saw that people could be supported to stay at home at the end of life if that was their preference. People and their families were included in end of life planning and staff were clear on what people’s preferences were.

Complaints were responded to in a timely manner. Outcomes of the complaints we viewed were factually correct and shared with the complainants with actions learned from the complaint.

The registered manager had complete oversight of the service. We observed that they conducted daily walk around of the service and had a team of support working alongside them to continue to monitor and improve the home.

Staff felt well supported by the registered manager, deputy manager, clinical lead and nurses. Relatives we spoke with felt the registered manger had largely contributed to the improvements within the home.

Audits were in place and regularly reviewed to monitor and improve the service. Clear action plans were in place to highlight where improvements were needed and the actions to be taken.

The service had worked closely with the local authority to improve the service and they acknowledged the work the service had un

At this inspection we found breaches in six regulations of the Health and Social Care Act 2008, including concerns that placed people at serious risk of harm. These were in relation to service user safety, falls prevention, mitigating known risks, training of staff, medication, staffing levels and shift management, the monitoring of fluids and the governance and leadership at all levels.

Following the inspection we asked the service to take some immediate action and told the home to produce an action plan to address the issues we had found. We returned to Four Oaks on 19 January 2018 to check that these actions had been taken and the action plan was being implemented. Our findings for the 19 January visit are reported at the end of each section of this report.

Full information about the CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded. You can see what other action we have told the provider to take at the back of the full version of the report.

Four Oaks is a ‘care home’. 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.

Four Oaks is a modern purpose built property which can accommodate up to 62 people in four separate units on two levels. Two units specialise in providing care for people living with dementia. At the time of our inspection there were 56 people living at Four Oaks.

At the time of our inspection there was a new manager in place at the home who told us they had started to complete the application from to be registered as the manager with the CQC. 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.

There were insufficient staff on duty to meet people’s assessed health and well-being needs. Staff were task orientated and were not visible in communal areas of the home as they were supporting people. Relatives told us they had had to support their loved ones themselves as there had not been any staff available.

Risks had not been clearly assessed and guidance was not available for staff to follow to mitigate any risks identified. For example people had had multiple falls and did not have a falls risk assessment in place. Hot kettles were left in the kitchenettes of each unit which people had access to with no staff being present. This posed a risk of scalding for some people living at the service. Behaviour management plans were not in place for those people who displayed behaviour that challenged the service.

Initial care plans for a person moving to the service were being written on the morning of their arrival. The staff team were not aware of this person’s needs. Most care plans were brief, generic and did not provide sufficient details to guide the staff to deliver person centred care. Some care plans were more detailed, for example the dementia care plans.

People and relatives said they had not been involved in developing the care plans.

Staff said they did not have time to access the care plans on the computer system used at the service. Handover of relevant information between shifts was not robust, with staff stating they did not always receive the information about any changes in people’s health or well-being.

Medicines were not safely managed. On the first day of our inspection the morning medicines round took so long that one person had to miss their lunch time medicine as there was not enough time between doses. There were no protocols in place as to when people were to be administered ‘as required’ medicines. One person had been administered an ‘as required’ medicine that made them sleepy. There was no indication in their care notes that they had been agitated and required this ‘as required’ medicine to be administered.

Fluid charts were used to monitor people’s fluid intake. However they did not specify a target amount the person should have each day and each day’s total fluid intake was not calculated, meaning the information was not analysed to ensure the person had had enough fluids.

There was no information available for the care staff regarding the amount of thickener to be used in a person’s drink to reduce the risk of choking.

Staff training was not up to date. The training matrices used by the home to identify staff training needs were not up to date. New staff were placed on the rota before completing the training identified as mandatory by the home and considered essential for new staff to carry out their role.

The service had a complaints procedure in place and we saw complaints had been responded to. However one response stated staff training was reviewed each week but this was not possible as the training matrices and staff training were not up to date.

There was a lack of governance at the home. Audit systems either were not in place or were not robust and had not identified the breaches in the Health and Social Care Act 2008 found at this inspection. Feedback from people living at the service, relatives, health professionals and staff about staffing numbers had not been acted upon as the service had an over reliance on a dependency tool that calculated how many staff were required and was not fir for purpose.

We have made a recommendation that the activity co-ordinators receive suitable training with regard to activities for people living with dementia.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures ’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

On our return to Four Oaks on 19 January 2018 to check what improvements had been made we found the service was implementing their action plan. Staffing levels had increased, including the number of nurses on duty in the morning. Senior care members of staff had been trained to administer medicines on one residential unit. The medicine rounds were monitored and completed in a timely manner. Protocols had been written for medicines prescribed ‘as required.’

Risk assessments had been reviewed and updated, although some, for example for managing people whose behaviour could be considered as challenging were not sufficiently detailed. A falls management system was in place, with crash mats being used to reduce the risk of injury and sensor mats in place to alert staff if a person was getting up and may need support.

Kettles were kept in a locked cupboard in the kitchenettes. Microwave ovens had been removed from the units for people living with dementia.

Staff handovers were taking place so that staff had up to date information about any changes in people’s support needs. Shifts had additional structure with allocation sheets being used on each unit to show who each staff member would be supporting.

Information was in place about the amount of thickener to use in people’s drinks where they had been assessed as being at risk of choking. The target amount of fluids to consumed each day and the actual consumed was not recorded.

Staff training had been arranged, with some already having been completed. New staff attended a three day training course before starting to work at the home. All staff had been enrolled on the relevant on-line courses.

A quality audit system linked to the provider’s C 360 compliance programme had started to be used. We discussed the use of the dependency tool with the deputy operations manager who said that the tool would be reviewed.

It was too early to assess what impact that these changes have made on the quality of care and the quality of people’s lives. We will look at this at our next inspection.

There was a manager in place who was in the process of registering with the Care Quality Commission. 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.

People told us they felt safe at the home. Toiletries were not stored safely and could have potentially caused harm to some people who used the service. Actions were taken immediately this was identified, to ensure people’s safety.

Recruitment was robust to help ensure staff were suitable to work with vulnerable people. Staff rotas evidenced good numbers of staff.

Safeguarding policy and procedures were in place and staff we spoke with demonstrated an understanding of safeguarding issues and were confident to report any concerns. Accidents and incidents were logged appropriately and analysed for patterns and trends.

Health and safety information was in place and up to date. Medicines were managed safely at the service and staff were trained appropriately.

Staff induction was thorough, training was on-going and staff supervision sessions took place regularly.

Nutritional and hydration records were in place, but were not all complete and up to date. The mealtime experience was good and a number of choices were offered with regard to food and drink.

The service was working within the legal requirements of the Mental Capacity Act (2005) (MCA) and the Deprivation of Liberty Safeguards (DoLS).

We observed care throughout the day and saw that interactions between staff members and people who used the service were friendly and respectful. People’s dignity was respected and care was offered and given discreetly and sensitively.

Residents and relatives meetings took place on a regular basis. Information was given to prospective users of the service and their families.

Advanced care plans, where the person’s wishes for when they were nearing the end of their lives had been expressed, were included within the care files.

Care files we looked at evidenced that care was person-centred. There was a range of health and personal information and people’s preferences, likes and dislikes were recorded.

There was an appropriate complaints policy and people felt able to raise concerns if they needed to. Compliments had been received from relatives in the form of thank you cards and letters.

The manager had been in place for a short time and had made some improvements to the service.

The manager was described as approachable by staff and relatives and staff members told us they were well supported.

We saw minutes of staff meetings, which were undertaken regularly.

Audits were undertaken regularly by the service. Audits for issues such as accidents and incidents were analysed to look at how continual improvements could be implemented. Reviews of care plans were undertaken but were not robust enough and had not always picked up inconsistencies in the records.