The Care Quality Commission (CQC) has rated Ocean Hill Lodge Residential Care Home in Newquay, Cornwall as inadequate and placed urgent conditions on its registration, following an inspection between 7 and 14 November last year.
The home is run by Ocean Hill Lodge Limited and provides accommodation and personal care for up to 18 older people. The inspection was carried out following concerns CQC received about the management of the service from the local authority.
From 20 November, CQC imposed conditions on the home to focus its attention on the areas where significant and immediate improvements are needed. These conditions prevent the home from admitting new residents without prior agreement from CQC, require leaders to take immediate action to improve people’s safety, and require the home to send monthly reports to CQC detailing progress.
Following this inspection, the service’s overall rating and how safe, effective, and well-led it is, have been rated as inadequate. Caring and responsive have been rated as requires improvement.
The service has been placed in special measures, which means in addition to the conditions above, it will be kept under close review by CQC to keep people living there safe whilst improvements are made.
Ocean Hill Lodge Residential Care Home had been rated under its previous provider as good overall.
Catherine Campbell, CQC deputy director of operations in the south, said:
“When we inspected Ocean Hill Lodge Residential Care Home, we found inconsistent management meant people weren’t receiving the level of care they had a right to expect. Leaders had very little oversight of people’s care and had failed to respond when things went wrong.
“Leaders didn’t have robust systems in place to keep people safe and they hadn’t addressed issues. During our onsite inspection the deputy manager was away and the remaining registered manager wasn’t based locally, had limited knowledge of the home, and didn’t understand the needs of the people living there.
“We found the registered manager was very reliant on more experienced staff to address shortcomings, such as developing people’s care plans, risk assessments, and ordering medicines. This put unnecessary pressure on staff to carry out tasks outside of their roles and impacted on the care they could provide.
“Staff hadn’t always acted when people’s risks and medical concerns changed. We found incidents where people had fallen or hit their heads, hadn’t been escalated to medical professionals. The home also hadn’t always notified the relevant external partners when incidents occurred, including CQC and the local authority.
“People’s care was task-based rather than centred around their preferences. There wasn’t enough staff to meet their needs and they didn’t always use agency staff to address those shortages. This meant staff left people alone for long periods of time without interaction or activities, and they couldn’t always support people to eat at mealtimes. Some people didn’t have care plans in place and where they did these weren’t always accurate or reflective of their needs and individual choices.
“In addition, leaders didn’t have an effective system in place to ensure people were protected from the risk of abuse. They hadn’t investigated when someone had experienced unexplained bruising. Five staff members hadn’t received safeguarding training and some were unsure how to raise concerns internally.
“We’ve imposed urgent conditions on the home’s registration to protect people and focus leaders’ attention on making immediate improvements. We’ll continue to monitor the home and won’t hesitate to take further action if we’re not assured people are being cared for safely.”
Inspectors found:
- Medicines records were incomplete and there had been a series of medicines errors. Staff had not always escalated medicines concerns with the GP. It was not always clear if staff competency had been assessed.
- Leaders had not ensured staff received the right training to carry out their roles, including in person-centred care.
- Staff told inspectors they did not feel valued, well-supported or informed about changes at the home. Some said they were asked to work longer hours, and their contracts had been changed without consultation.
- Risk assessments had not been completed for some new residents and it meant staff lacked guidance to support people safely.
- People living at the home gave mostly positive feedback about their care but feedback from relatives was mixed. One family member said people could be kept waiting for help and call bells would ring without an answer from staff.
- Feedback was not always used to make improvements. There was no process in place to gather staff feedback. Although the home held meetings with people and their relatives, inspectors were told issues raised were not always addressed.
- Environmental risks had not always been addressed. Actions following an electrical safety check hadn’t been completed. Rooms which should not be accessible to residents were found with doors open for long periods, or with the key in its lock.
The report will be published on CQC’s website in the coming days.