We returned to inspect The Oasis on the 16 October 2018 to complete a focused inspection which was unannounced. This was to follow up on warning notices we had served on the provider and registered manager following our inspection on 10 and 11 April 2018. At that inspection, there were concerns that aspects of the service were not safe, effective, responsive and well-led. This was because the service was not meeting some legal requirements. We found breaches of Regulation 12 Safe Care and Treatment and Regulation 17 Good Governance and issued warning notices are part of our enforcement actions. This report will report on the findings in respect of the warning notices and information of concern we had.

Prior to the inspection we had received new information of concern. One of these concerns was in respect of people being supported out of bed early so the day staff would have more time to do other duties. We arrived early to look at this and found this was not a concern. We noted three people were up early. We talked with one person and asked them if they liked getting up early. They replied, “I go to bed early and am ready to get up early”. We walked around the service and noted that some people were still in bed, some getting up and other people waiting for support from staff. We spoke with a member of the night staff who said, “We only get people up who have requested it”.

We shared other concerns we had received with the registered manager to which they were able to respond appropriately to. These were about how the service was staffed; how staff delivered personal care; how a person’s skin had been looked after; how staff spoke to one person negatively, how a person’s medicines were being recorded and, infection control measures in the kitchen. They advised us the director of compliance would be advised of these concerns and would communicate with us.

Another breach in Effective from the previous inspection, in relation to staff training will not be reviewed fully until the next comprehensive inspection. This means Effective cannot be rated higher than Requires improvement.

The registered manager had deregistered when we inspected but continued to work in the service during a handover period to a new manager. Since this inspection, this has been corrected and the registered manager was again in this role. 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. Since the last inspection, changes had been made to the senior management of the service. There was a new director of compliance and a new administrator. Some roles were still being defined as two staff were leaving and supporting new staff to understand and take over their responsibilities.

No risks, concerns or significant improvement were identified in the remaining Key Question of the service being Caring through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

The Oasis 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.

The Oasis accommodates up to 35 older people who may be living with dementia. On the day we inspected, 29 people were living at the service.

We found positive steps had been taken to make improvements since our inspection in April 2018 but not all aspects had been fully implemented yet. The service was in a process of review and restructure which impacted on meeting all the issues fully. A

The inspection took place on the 10 and 11 April 2018 and was unannounced. This is the first inspection for this service since the provider’s registration changed on the 27 February 2017. Evidence for this inspection provided by the registered manager and provider at times, predated this registration date.

Since February 2017, we have received two whistle blower concerns and three complaints. These raised concerns about the equipment being used in the service, one concern about end of life care, concerns about how staff were recording when they administered medicines and the training of new staff. A whistle blower also raised a concern about the staffing, language ability of staff, medicines being given to people without their consent and alarm mats being in use that are causing people to fall as they slipped under foot when they stood on them. These were raised with the provider who responded. However, we also checked these concerns on this inspection. We found concerns in some areas which are summarised below.

The Oasis is registered for 35 older people who may be living with dementia. On the days we were at the service, 31 people were living there. 19 people were living with dementia or noted to have a level of “confusion” and/or short term memory loss. Staff did not offer nursing care; nursing care is provided by the community nursing team.

The Oasis 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.

A registered manager was employed to oversee the running of the service. 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. One of the providers also managed aspects of the service. A deputy manager oversaw much of the administration and shift leads managed the day to day running of the shift, speaking to GPs, medicine administration and organising staff. Different staff had lead roles such as in end of life care and infection control.

The governance framework did not ensure responsibilities among staff were clear. Throughout this inspection, we found staff roles were poorly defined. Records about the same issue were held by different staff in different parts of the service. The registered manager and registered providers deferred accountability to each other rather than remaining accountable or at least knowledgeable about how that area of running the service was being maintained.

The registered manager and provider failed to have effective quality assurance systems that ensured all areas of the service were safe and of the quality expected. For example, during the inspection we identified a number of areas that were not being monitored. This included infection control; ensuring people had the required risk assessments in place; staff were suitably trained, supported and informed and people’s records reflected their choice. Where audits were completed, these did not evidence what action had been taken to resolve the issues identified.

People were not always protected by safe infection control and food handling practices. We witnessed poor infection control practices. All staff had not been appropriately trained to keep people safe. The laundry was not being managed safely. Chemicals were not being handled in line with legislation. We advised Environmental Health of these concerns.

People were not always ensured any risks would be identified or addressed. People at risk of choking, high or low blood sugar (diabetes), and/or due to the use of blood thinning drugs did not have their risks assessed. People’s care plans only contained minimal inform