This unannounced inspection took place on 3 September 2018. At the last inspection carried out on 31 May and 2 June 2017, we found that there were areas which required improvement including three breaches of regulations. At this inspection, we found that the service had made some improvements, however there remained areas which required improvement. We found that there remained a breach relating to good governance and quality assurance systems.

Oak Farm is a ‘nursing home’ and a rehabilitation support unit which provides care and support to people who are living with a brain injury. At the time of our inspection there were 36 people living at Oak Farm. The provider has on site a multi-disciplinary team which includes a physiotherapist and two part-time occupational therapists as well as therapy and activity assistant staff, nurses and care staff. People in care homes receive accommodation and nursing, personal care or rehabilitation as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Oak Farm accommodates people in two adapted buildings across a one floor. There were 36 people living in the home when we inspected, many of whom were living with complex health conditions including the effects of traumatic brain injury.

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. The registered manager was not available at the time of our inspection, and we were supported to carry out the inspection by other members of staff, such as administration, the area manager, the care coordinator and the clinical lead.

At our last inspection of 31 May and 2 June 2017, we found that staff did not always obtain consent from people. Improvements were needed with regards to the management of medicines, staff training, mealtimes and systems for monitoring the service.

At this inspection, staff obtained consent from people before delivering care. Staff understood people’s mental capacity and supported them to make decisions.

There had been improvements in the management of medicines, and there were protocols in place when needed. However, further improvements were needed in the administration of topical medicines.

We found at this inspection on 3 September 2018 that further improvements were needed in respect of the quality monitoring of the service. The systems for identifying issues and monitoring the service were not fully effective. Medicines audits had not identified that there was limited and inconsistent recording around some prescribed items, and the auditing process did not include checking the medicines administration records (MARs).

Improvements were needed to ensure that care plans remained up to date and relevant, as they did not always contain sufficient information about people’s needs. For example, in some areas such as communication, skin integrity and activities or occupation.

There were enough staff to keep people safe and they had received some further training related to supporting people living in the service. However, further improvements were needed in this area, as some poor practice remained relating to manual handling. Staff felt supported in their roles.

There were improvements in staff supporting people in a caring way, however some poor practice remained. Staff were caring towards people’s families.

Staff knew how to report safeguarding concerns and there were health and safety checks which contributed to keeping people safe.

People received a choice of food and enough to eat and drink. They were also supported to access healthcare. People received in house treatment from nurses, physiothera

Oak Farm is a rehabilitation support unit which provides care and support to people who are living with a brain injury. At the time of our inspection there were 36 people living at Oak Farm. The provider has on site a multi-disciplinary team which includes a physiotherapist and an occupational therapist

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.

At this inspection we found that the provider was not meeting the requirements of three Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because people’s medicines were not always managed safely, and there was not always an adequate skill-mix of staff deployed across the home. We also found that there were not fully effective systems in place to monitor the service and identify potential problems. You can see what action we told the provider to take at the back of the full version of the report.

Staff did not routinely obtain verbal or implied consent before delivering care, and care was not always delivered in a compassionate manner. Staff did not take opportunities to give people choices, however where people had made choices, these were respected.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) Deprivation of Liberty Safeguards (DoLS) and report on what we find. Mental capacity assessments had been carried out for specific decisions where appropriate and some people had been lawfully deprived of their liberty.

Improvements were needed with regards to the administration and management of medicines. Some medicines were at risk of being given inappropriately and stock levels did not correspond with records.

Improvements were needed with regards to staff training in challenging behaviours, manual handling and supporting the specific complex needs of the people at Oak Farm.

The systems in place to monitor, analyse and improve the service and identify concerns were not always effective.

We found that improvements were needed to the mealtime experience for people as staff did not always support them in a dignified, compassionate and interactive way, to eat their meals.

Staff supported people to eat special diets when they needed, and to drink enough. Staff also supported people to access healthcare when they required. There were enough staff to keep people safe and there were safe recruitment strategies in place. However, there was not always an adequate skill mix of staff available to meet people’s needs. People were supported to access healthcare promptly when they needed it.

There were comprehensive care plans in place for people and staff delivered care to individuals that met their specified preferences. The therapy staff supported people to maintain their mobility and to set and achieve goals. There were activities that people could get involved in during the week, and people were supported to access the community.

There was not always visible leadership in place throughout the home, however the staff worked as a team and were supported by the management team. People were not always asked for feedback in a way that they understood, however people knew how to complain.