Oakley House Limited is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Oakley House is registered to provide personal care for up to 11 people. There were five people living at the service at the time of our inspection.

This inspection site visit took place on 14 November 2018 and was unannounced.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. On the day of the inspection the registered manager was on leave so instead we were supported by the provider.

There were aspects to care delivery that were not safe. Where a risk had been identified there was no assessment of this risk with measures in place. Accidents and incidents were not always recorded onto incident forms. Staff were not always following best practice in relation to infection control. There were aspects to the environment that required improvements. We have recommended that they are always the appropriate numbers of staff available as at times they were lacking.

Staff did not always have the competencies they needed to meet people's needs and ensure their safety. Although training was being provided staff were not always providing the most effective care. People’s rights were not always protected because the staff did not always act in accordance with the Mental Capacity Act (2005) MCA or Deprivation of Liberty safeguards DoLs. Mental capacity assessments were not always taking place particularly when specific decisions needed to be made. Where people had capacity, their rights were at times were being restricted.

There were times where people were not always treated with dignity. People were not always involved in the planning of their care and were not always supported with their independence. Care plans lacked detailed around the specific needs of people particularly where they had a mental health diagnosis. Improvements were needed around the activities and access to the community.

Audits and surveys were not being used as an opportunity to make improvements.There were insufficient processes in place to ensure that people were aware of how to complain. The provider was not delivering on their statement of purpose.

We saw that medicines were being managed in a safe way and there were systems in place to ensure that people were safe in the event of an emergency. There were aspects of risk assessments that were appropriate to ensure that risks to people were reduced. Robust recruitment checks were in place that ensured that only suitable staff worked at the service.

Pre- admission assessments took place before people moved in to the service. People at risk of malnutrition and dehydration had systems in place to monitor their health. People were protected from the risk of abuse as staff understood what they needed to do should they suspected abuse was taking place.

People enjoyed the food at the service and were offered choices of meals. Referrals to healthcare professionals were being completed where required and people received healthcare support when needed.

There were times where staff at the service were observed to be kind, caring and respectful towards people. People that were able could access all areas of the service when they wanted.

People had the opportunity to attend meetings to feedback on aspects of care. Staff said they felt supported and valued. We saw that the registered manager worked with organisations outside of the service in relation to people’s care. Notifications that are required to be sent to the C