On 11 November 2016 we inspected The Oaks Care Home and found them to be in breach of one regulation under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breach of Regulation 12 was in relation to improvements needed to protect people from the risk of infection. There were some other minor improvements also needed. We rated the service as ‘Requires improvement’ for the key questions of Safe, Responsive and Well Led and ‘Good’ in Effective and Caring. We asked the provider to complete an action plan as to how they would improve the service. The provider wrote to us showing the actions they had taken since our last inspection.

We carried out this unannounced inspection on 28 November 2017 to see if the provider had made the necessary improvements to the service. We saw that improvements had been made to ensure people were kept safe from the risk of infection, records were more consistent, people had more opportunities for leisure activities and improvements had been embedded in practice. All of the key questions were rated as ‘Good’ and the service received a rating of 'Good' overall.

The Oaks 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 care home was registered to provide a service to up to 61 people in one building on two separate floors. These included people with a physical disability, those living with dementia and people receiving end of life care.

However, after the recent refurbishment people were accommodated only on the ground floor until further refurbishment was undertaken. At the time of the inspection, there were 32 people being supported by the service.

A registered manager was 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.

There were systems in place to safeguard people from avoidable harm and staff knew how to report any concerns. The risk assessments undertaken provided staff with the necessary information and guidance on how risks to people could be minimised. The service regularly reviewed their staffing arrangements to ensure there were sufficient staff available to support people safely.

Recruitment processes were in place for the safe employment of staff. People’s medicines were managed and administered as prescribed and infection control procedures were followed in order to keep people safe and well. Systems were in place to learn from incidents and accidents and to improve the service as a result.

An organised programme of induction, training, supervision and appraisals for staff were in place. Staff had the knowledge and skills to care for people effectively. They understood their roles and responsibilities to seek people’s consent prior to care being provided.

People were supported to have a choice of food and drink and to have a balanced and varied diet. The registered manager and staff ensured access to healthcare services were readily available to people and worked with a range of health professionals to implement care and support plans.

People’s needs were met by the design and decoration of the premises. They had been involved in the recent refurbishment and could access all areas including the grounds.

Systems were in place to ensure that people’s rights were respected and protected under the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). Where people did not have capacity to consent to their care or make decisions about their lives, this was managed in line with the requirements of the MCA.

Staff were respectful and compass

We carried out this unannounced, comprehensive inspection on the 10 November 2016 to check that the provider had made the improvements required following our inspection on 15 June 2016.

During an earlier inspection in December 2015 we identified a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service was placed into Special Measures and we imposed a condition on their registration to not admit any further people into the service. We told the provider to take urgent action and kept the service under review, with the expectation that significant improvements would have been made within a six month timeframe.

At our inspection in June 2016 we found that robust and sustainable audit and monitoring systems were still not in place to ensure that the quality of care was consistently assessed, monitored and improved. The provider had failed to recognise and identify significant failings impacting on the quality of service provision, and risks to people. We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in respect of Regulation 9 Person centred care, Regulation 10 Dignity and Respect, Regulation 12 Safe care and treatment, Regulation 14 Meeting nutritional and hydration needs, Regulation 16 Receiving and acting on complaints, Regulation 17 Good governance, Regulation 18 Staffing and Regulation 19 Fit and proper person’s employed.

You can read the reports from our last comprehensive inspections, by selecting the 'all reports' link for The Oaks Care Home on our website at www.cqc.org.uk.

The provider had acted on our concerns and at this inspection we found that there was a positive, open and inclusive culture in the service. There had been significant progress made in making the required improvements, however there were some aspects of the service provision where further work was needed to ensure that safe and responsive care was delivered at all times.

The Oaks Care Home provides care for up to 61 people who are elderly and frail with complex needs that may include nursing and/or dementia related needs. On the day of our inspection there were 25 people living at the service.

There was currently no registered manager but an interim manager was 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.

Improvements were still needed to protect people from the risk of infection. Some staff were observed providing care without using the appropriate personal protective equipment such as gloves and aprons.

Although significant progress had been made with the care plans we found that records were not always consistent. However, care plans were now person centred and reflected the care and support that each person required and preferred to meet their assessed needs.

People generally felt that there were sufficient numbers of staff to care and support people according to their needs. People and their families were positive about the care they received from staff who respected their privacy, dignity and independence.

Staff demonstrated a knowledge and understanding of people’s preferred routines, likes and dislikes and what mattered to them. Staff were being encouraged and supported to have a greater understanding of how they could ensure a holistic approach to people’s care. They had completed additional training to equip them with a greater awareness and understanding with regards to supporting people living with dementia.

There were improvements in the provision of activities. There were times when the opportunities for social interaction were more limited but this was being addressed with the introduction of an additional activities co-ordinator

We carried out this unannounced, comprehensive inspection on the 15 June 2016 to check that the provider had made the improvements required following our inspection on 16 December 2015.

During our inspection in December 2015 we identified a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service was placed into Special Measures and we imposed a condition on their registration to not admit any further people into the service. We told the provider to take urgent action to address and improve staffing levels, medicine management, infection control practices, cleanliness and hygiene, governance and management systems. We received an action plan from the provider and we have kept the service under review, with the expectation that significant improvement to have been made within a six month timeframe.

Despite assurances given by the provider and management following our previous inspection, at this inspection we found that robust and sustainable audit and monitoring systems were still not in place to ensure that the quality of care was consistently assessed, monitored and improved. The provider had failed to recognise and identify significant failings impacting on the quality of service provision, and risks to people.

The Oaks Care Home provides care for up to 61 people who are elderly and frail with complex needs that may include nursing and/or dementia related needs. On the day of our inspection there were 32 people living at the service.

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 overall governance and oversight was not robust enough to ensure that all areas of the service were working well and improving. Where actions had been taken to improve there was no effective system in place to ensure those actions were being implemented and sustained. People continued to be at risk of infection, poor moving and handling, poor pressure relieving management and poor record keeping. Staff did not have the resources, including effective training, to support them to provide high quality care.

Care was not personalised and delivered in a planned and consistent way. The needs of people living with dementia were not considered and staff were not aware or understood how dementia affected those individuals in their day to day living. Staff had also not had training to help them understand other health needs of people for example, diabetes.

We found that there continued to be poor standards of cleanliness and infection control. The kitchen and kitchen equipment were unclean and unhygienic, and people were at risk from the unsafe management of food.

Recruitment processes were not robust and operated effectively to ensure newly recruited staff were suitable for the role.

Since our last inspection action had been taken to address significant shortfalls in medicine management however further improvement was needed to ensure people received their prescribed medicines at the right time and ensure the correct period of time between doses.

There was a lack of oversight from all levels of management and quality assurance systems were not effective. This meant improvements identified in their action plan were either not being properly implemented or sustained. Resulting in continued non-compliance with regulations and poor outcomes for people.

This is the second time the service has been found to be Inadequate overall and continues to be in Special Measures, The Commission is considering its enforcement powers.

This unannounced inspection took place on the 16 December 2015 in response to information of concern we received from a variety of sources.

We found at this inspection that people’s safety had been compromised in a number of areas. This included the management of people’s medicines, the monitoring of people at risk of and support for people with pressure ulcers, care and support for people with indwelling catheters and monitoring and support for people with their food and fluid intake.

Staffing levels were insufficient to meet the needs of people who used the service. The provider did not have a system in place to ensure continuous assessment of staffing levels to make the changes required when people’s needs changed. There were no nurses directly employed by the provider. All nurses were employed through nursing agencies. There was no clinical lead in post with delegated responsibilities and oversight of nursing tasks and assessment of nursing competencies.

There was a lack of regular safety audits of medicines management within the service. This had resulted in medicine administration errors not being identified and no action taken to mitigate risks and protect people from the risk of harm.

In response to our concerns identified at this inspection we issued an urgent action letter on the 16 December 2015. The provider in response sent us an action plan which told us what action they would take in response to our concerns to mitigate the risks to people’s health, welfare and safety.

The Oaks care home provides nursing and personal care with accommodation for up to 61 people, some of whom required specialist palliative (end of life) care. On the day of our inspection there were 53 people living at the service.

There was a registered manager. 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.

Staffing levels were insufficient to meet the needs of people who used the service. The homes manager worked shifts to cover the rota. There was no member of staff delegated to carry out the role as clinical lead. There were no qualified nurses employed directly by the provider.

We found significant concerns in relation to medicines management. People were not receiving their prescribed pain relief medicines as required. People did not always have access to medicines due to staff not managing stock effectively and stocks of medicines ran out. There were insufficient numbers of trained staff available to administer medicines and excessively long medication rounds. Medication audits were poor and did not identify errors. Poor auditing meant that stock did not always balance and discrepancies were not identified by the provider.

There was also a lack of systems and auditing of the cleanliness of the environment and maintenance of the building. We found poor infection control practices and areas of the service which were not acceptably clean. There were strong odours throughout the service and the carpets and furnishings found to be dirty.

People were not supported to access personal care. Some people were found not have been supported with a bath or shower for up to three months. People were observed to look unkempt and have nails which had not been cared for and supported to clean.

The service was not well-led. There was a lack of clinical governance. The registered manager was not a trained nurse and the post of deputy manager where previously this person would have been the clinical lead had been vacant for several months. There were no clinical audits in place which would have identified the shortfalls we found at this inspection. We were therefore not assured that action was taken to identify and mitigate the risks to people’s health, welfare and safety.

There were no effective systems in place to monitor effectively and proactively the quality and safety of the service provided. The provider failed to operate effective systems and processes to make sure they assessed and monitored the quality and safety of the service on a regular basis. The environment and equipment for people was not suitable to support people safely and ensure people’s individual needs were met.

The provider did not have a robust system in place to evidence their response and outcomes following investigations into people’s concerns and complaints about the quality of the service provided.

During this inspection we identified a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special Measures’.

The service 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.

We spoke with six people using the service, two relatives and a friend of a person using the service. People told us that they were very happy with their care and that staff were friendly, nice and kind. One person commented, “I am very happy here, they look after me”. One person said. “I am very happy at the home, I have no complaints”. A relative commented, “Nice atmosphere, staff are very nice there are the occasional staff that don’t fit in, but they soon leave, there is a good work ethic in the home”. A relative stated that, “My relative receives excellent care; the staff treat them very well”. Another relative commented, “Although the demands are great the staff look after my relative very well, the food is average, the quality could be better”. We received varied feedback from people using the service and relatives about the quality of the food. Mostly people were satisfied, however comments included, “The quality of the meat could be better” and “Not always a good variety, meals, especially deserts can be a bit repetitive”.

We looked at care records and found that people had appropriate assessments and were cared for according to their needs. We saw that there was enough equipment to promote people’s independence and comfort. We found that systems were in place to ensure the service was being maintained.

Staff told us that they received training and support to ensure that they had the skills, experience and knowledge to carry out their roles.

We spoke with five people who used the service, two relatives and five members of staff as part of this unannounced inspection. People who used the service told us they felt safe and were happy with the care they received.

One person stated that "they enjoyed playing dominoes with the staff."

We inspected six regulations and found that the service was meeting the personal, emotional and healthcare needs of the people using the service. We found that the environment was maintained safely and that all health and safety checks were up to date

Three people told us they were pleased with the choice of menus available. At lunchtime we carried out a short observational framework inspection (SOFI). We found that people were appropriately supported with their meals in a timely and respectful manner and were provided with at least three choices. The catering staff spoke with people to see if they had enjoyed their meal and to also listen to any ideas people had about the meals.

We found that all mandatory training was up to date.

People with whom we spoke told us that they had recently been asked their views about food and menus. They said that the meals were getting better but everyone agreed "there was room for improvement."

People with whom we spoke told us that they thought that the staff were there for them when they needed them. A relative with whom we spoke told us that people would like more outings and relatives could help organise them rather than just rely on the staff.

People who use the service and relatives told us that the food was quite good but there could be more choice. They felt the staff looked after them well, they could talk to someone if they were not happy, or felt worried about anything. Generally people with whom we spoke told us that the home was kept clean and neat and tidy.

Most of the relatives with whom we spoke told us they thought that there were not enough staff on duty for the amount of people at the home. The views of the people, who could tell us verbally about the availability of staff, all said that whilst they all did a good job, they were very busy and there were just not enough of them to go round everyone.