About the service Oak Lodge is a residential care home providing accommodation with personal care to older people, some of whom were living with dementia. The service can support up to 28 people in one building over two floors. At the time of this inspection, 15 people lived at the service
People’s experience of using this service and what we found
Risks which affected people's health, safety and wellbeing were not always documented. This meant that staff did not always have adequate information to manage and mitigate risks to people. Accidents and incidents had not been thoroughly recorded and action had not been taken to reduce risks.
Staff had not been trained or assessed to carry out key tasks for people such as medicine administration or supporting them with catheter care.
Staff did not have access to adequate supplies of personal protective equipment (PPE). The service did not have sufficient infection prevention and control measures in place. Government guidance in relation to COVID 19 was not followed.
Safeguarding concerns had not been reported by staff and management. The registered manager was not clear of their role and responsibility in relation to safeguarding.
Regular deep cleaning regimes were not in place and areas of the home such as the laundry and sluice were dirty and cluttered.
Medicines had not been managed safely. Staff had not received appropriate training and competency assessments. Guidance from other professionals had not been followed.
Quality assurance processes were in place to monitor the quality and safety of the service, but these did not identify serious concerns we found and contradicted practice we observed. There was a clear lack of provider oversight and they had not ensured effective and competent management was in place.
Some staff members we spoke with raised concerns about the management of the service.
We did observe people appeared comfortable and happy with staff interaction with them.
For more details, please see the full report which is on the Care Quality Commission website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (report published 19 October 2019.)
Why we inspected
Serious whistleblowing concerns were received by the local authority safeguarding team in relation to management of the service and the quality of care and support that was being provided. There had been a number of safeguarding concerns raised by other professionals. As a result, we carried out a focused inspection to review the key questions of safe and well-led only.
We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.
The overall rating for the service has changed from good to inadequate. This is based on the findings at this inspection.
We have found evidence that the provider needs to make substantial improvements. Please see the safe and well-led sections of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Oak Lodge 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 the safety of people and the risk of harm. We also identified breaches in relation to the management and monitoring of the service, premises and equipment and staffing 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
We will continue to monitor information we receive about the service and we will continue to work with partner agencies. We will also request a specific action plan to understand what the provider will do immediately to ensure the service is safe. We will work alongside the provider and the local authority to closely monitor the service. We will return to visit in line with 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.