Little Oldway

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We identified 1 breach of legal regulations. People were not consistently protected from the risk of harm and staff did not always make safeguarding referrals in line with the providers policy and procedures. Staffs’ approach to the management of risk was inconsistent and we could not be assured that staff had access to all the available information to support people to manage and mitigate risks to themselves or others. We found some people were subject to blanket restrictive practices; there was no system in place for reviewing restrictive practice to ensure that any restrictions remained the least restrictive option. This meant the provider could not be assured that any restrictions were or continued to be in a person’s best interests. The provider could not be assured that people were supported by staff who had the skills and experience to meet their needs safely. We have made a recommendation in relation to creating a dementia friendly environment and meeting the needs of people with a sensory impairment. However, people told us they felt safe living at Little Oldway, and relatives felt confident with the care and support provided. Other risks to people’s health and wellbeing were being managed well. Where people required specialised equipment to keep them safe, we saw this was in place and staff followed people’s individual risk assessments. People were protected by safe recruitment practices. We have asked the provider for an action plan in response to the concerns found at this assessment.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People who were able to share their views with us, told us they were happy living at Little Oldway. Comments included, “It’s nice here, it’s peaceful,” “Yes, I am getting on fine (here) thanks”. And “Yes, I feel safe, the staff are good workers. I’ve got no problems with the staff; the place is run well”. However, one person said, “This place is overcrowded, it’s noisy and the staff always have the radio on. It’s a lovely day, on a day like this they (staff) should take people outside”. Most relatives we spoke with did not raise any concerns about people’s safety. Comments included, “My mother-in-law would not be there if I did not think it was a good place,” “It’s very safe, I am really happy,” “Its excellent. They contact us when needed and are always available.” And “The staff are superb with mum and are respectful to me.” However, one relative said, “I don’t get much communication. Mum has attacked others and has had falls, and they don’t always tell me.” Another said, “Communication is sometimes poor, they don’t call you back.”

The care manager described how the service protected people from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. All of which was under pinned by the service’s policies and procedures. Staff had received training in safeguarding adults and were able to tell us the correct action to take if they suspected people were at risk of abuse and/or avoidable harm. One member of staff said, “I have no concerns about people’s safety and if I did, I would report it straight away.” Another said, “I would go to [care manager name] first and then to [nominated individuals name]. However, we found whilst staff at all levels were able to tell us the correct action to take if they suspected people were at risk of avoidable harm or abuse. They failed to recognise or escalate some incidents or concerns within the organisation or to Torbay Council’s safeguarding team in line with the provider’s safeguarding policy. The care manager and nominated individual described the system for recording, investigating, and monitoring accidents and incidents within the service. The care manager explained that all incidents were logged on an incident form and reviewed by the management team to ensure the appropriate action had been taken. This information was then monitored monthly by the management team to identify any themes or trends. However, we found staff were not always using the form provided and there was no evidence that some incidents had been reviewed or that the information was being monitored by the management team.

During the assessment we observed many positive interactions between people and staff. For example, we saw some staff members had a very person-centred approach and really took time to meaningfully engage with people prior to their lunch. We saw how some staff sensitively comforted and redirected people when they became emotionally distressed or offered assistance sensitively when people needed some support to maintain their personal care. However, we also saw that some people went for very long periods without any interactions from staff, and some interactions were task orientated and not person centred.

There were systems in place to protect people from abuse, including policies, procedures and training for staff. However, we found these were not effective and there was a lack of management oversight. We reviewed incident information and identified there had been 5 recorded incidents involving people hitting each other between 14 December 2023 and 26 February 2024. Neither the care manager or nominated individual were able to tell us what action had been taken to mitigate ongoing risks or if this information had been referred to the local authority / CQC for further follow up. We have shared what we found with Torbay Council’s Quality Assurance and Improvement Team and asked the care manager to review each incident and make the appropriate referrals. The failure to effectively establish and operate systems to investigate and report allegations of abuse placed people at an increased risk of harm. This was a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this is usually through Mental Capacity Act 2005 (MCA) application procedures called the Deprivation of Liberty Safeguards (DoLS). We found some people living at the service had in place either a door alarm or sensor to monitor their movement / whereabouts. Whilst these restrictions had been processed in line with MCA/DoLS there did not appear to be a need for some of those restrictions. For example, one person had in place a door alarm in case other people entered their room. This meant the restriction had been applied for the wrong reasons and therefore did not have a legal basis. The failure to provide care and support in line with the Deprivation of Liberty Safeguards code of practice was a breach of regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People we spoke with told us they were happy, felt safe and liked the staff supporting them. Most people living at the service were not aware of their care plan and/or associated risk assessments due to their individual needs. We received a mixed response from relatives about their involvement in their loved one’s care. Most relatives consistently told us staff kept them updated with any changes. Comments included, “He had a care plan review in February, and they talked to us about it,” “They are good at letting me know if she is not well,” “They consult me and let me know if GP is called,” “They keep me informed of changes in procedures or of [person’s name] condition.” They phone up if there is a problem,” “They [meaning staff] tell us everything that goes on, like about his medication. They communicate all the time, every 6 or 7 days. If he’s not well, they tell me immediately.” However, one relative said, “No one ever phones us. Had to struggle to get a care plan review, would phone 3 or 4 times, had to chase to get them to discuss care plan with us. It is full of contradictions.”

The care manager described how the staff assessed people’s needs before offering a placement and developed care plans and risk assessments, which were reviewed on a regular basis. Staff told us they knew people well and had a good understanding of their needs. Staff were aware of people's individual risks, potential triggers and signs that might show the person was becoming unwell or anxious. Staff described how they supported people to manage their emotional distress or anxieties.

It was clear from our observations that staff had developed good relationships with people. Staff we spoke with had a good understanding of people’s needs. We saw how staff were anticipating people’s needs and identifying triggers and redirecting, preventing people experiencing emotional distress and or increased anxieties. For example, we saw how staff took time to explain to people what they were doing and allowed people time to process information.

The care manager described how the service assessed people’s needs before offering a placement. Assessments were used to develop person centred care plans and risk assessments. These were reviewed on a regular basis with the involvement of people, relatives, and staff. The provider monitored compliance through a care plan audit completed by the care manager and members of their senior team. Some care plans and risk assessments reviewed by the inspection team contained clear information regarding risks and provided guidance for staff on how to support people to minimise those risks. For example, detailed care plans and risk assessments were completed in areas such as hygiene, nutrition, mobility, moving and handling and falls. However, we found staffs’ approach to the management of risk was inconsistent and we could not be assured that staff had access to all the available information to support people to manage and mitigate risks to themselves or others. For example, we identified information relating to accidents and incidents which was not being reviewed. At the time of the assessment neither the care manager or nominated individual were able to confirm what action had been taken to further investigate these incidents or to mitigate, reduce or prevent reoccurrence. This meant the provider could not be assured that action had been taken. This placed people at an increased risk of avoidable harm as documented in the safeguarding section of this report. We noted some people’s care records contained conflicting information and lacked detail. Daily care notes completed by staff were task orientated and not person centred. The care manager and nominated individual who told us they had introduced a new electronic care plan system approximately 18 months ago, but this was not working as well as they hoped. Following the assessment the nominated individual told us they were currently exploring a system to improve better recording of the care provided.

People were either not able to share their views with us or did not raise any concerns about their living environment. We received mixed feedback from relatives about people’s living environment. Comments included. “They are constantly refurbishing inside and outside. They redesigned the garden to make it accessible and beautiful. It’s a nice place in a good position,” “It’s spotless, you see cleaners around all the time, everything is being sanitised,” “The home is clean and does not smell.” However, some relatives said, “Overall the home looks a bit grubby,” “It looks a bit run down,” “It always smells, even my [sister] commented on that,” and “I have had an issue with smell.”

The care manager and nominated individual told us there had been significant investment with regards to the environment since the last inspection. For example, there had been a complete redesign of the garden, replacement flooring, refurbished ground floor bathroom and 1st floor wet room, and a complete interior re-paint, alongside the redecoration of some people’s bedrooms. The nominated individual told us they were aware that some aspects of Little Oldway were still in need of some attention and assured us there was a plan in place to address these areas.

We toured the service with the care manager and found some areas of the service looked tired and needed attention. For example, some hallway carpets were worn, heavily stained and looked grubby. We saw that several strips of wallpaper had been torn and some walls needed painting. One riser/recliner (chair) in the dining room was very stained and some equipment used to support people was worn and not clean. On both days of the assessment, we noted there was an unpleasant odour coming from one end of the building where the main lounge was situated. We discussed what we found with both the care manager and nominated individual, whilst they could not detect the odour, they told us this area had recently been deep cleaned. There was limited dementia friendly signage to support people to navigate their way around the home. We recommend the provider reviews the accommodation with regards to best practice guidance about creating a dementia friendly environment and meeting the needs of people with a sensory impairment. We also noted that staff were using part of the main lounge to store people’s walking frames and wheelchairs. When we returned for the second day of the assessment all this equipment had been removed.

The premises and equipment were maintained, and regular checks were undertaken in relation to the environment and the maintenance and safety of equipment. For example, water temperature testing, portable appliance testing, window restriction and moving and handling equipment was regularly serviced and checked for safety. Fire safety systems were serviced and audited regularly, and staff received training in fire awareness. Systems were in place to prevent and control the risk of infection and we observed staff wearing appropriate personal protective equipment (PPE) to reduce the risk of cross contamination and the spread of infection. Environmental audits were carried out on a regular basis and the provider had developed a programme for planned refurbishment alongside their daily maintenance schedule. For example, records showed in the first half of 2024 the provider had purchased a new commercial oven, fridge freezer as well as a new boiler. We saw planned works included replacement windows and the resurfacing of the car park.

People were not able to tell us if there were enough staff to meet their care and support needs. However, people who were able to share their views told us they liked living at Little Oldway and the staff supporting them. Relatives did not raise any concerns with us about staffing levels or staffs’ competencies. Comments included, “There are always enough staff around when you go, there is always carers milling around and keeping an eye,” “I visit on a Saturday afternoon and there are always enough staff,” “Always see two or three staff around when we visit,” “You hear the buzzer, but not for long. Not sure if all staff are trained, but always see them being compassionate, professional, and loving,” And “I feel welcome when I go. Always get a smile, always answer questions, or bring a senior over to talk to you”.

The nominated individual told us there were enough staff to meet people’s needs safely. Whilst the service did not use a dependency tool to determined staffing levels they stated, “As a minimum we have 1 senior care assistant and 5 care assistants on shift between the hours of 8am and 8pm, 3 care assistants at night and additional support with medicines between the hours of 6pm and 9pm.” The care manager told us care staff are supported by several ancillary staff daily which include 2 domestics, a laundry assistant, a cook, a kitchen porter, an activities co-ordinator, a maintenance person, and a gardener. Staff confirmed they attended training, received regular supervision, and told us there were enough staff on duty to support people and keep them safe. One member of staff said, “We have lots of training, online and face to face”. Another said, “I have regular supervision, you can talk about anything, work, or my personal life. I feel very supported.”

There were enough staff to meet people’s assessed needs. There always appeared to be staff within the main lounge / dining area and we did not hear people’s call bell’s ringing for prolonged periods of time, which might indicate that people were waiting for assistance.

We looked at the recruitment information for 3 staff members. Records confirmed a range of checks including application, interview, and Disclosure and Barring Service (DBS) checks were conducted before staff started working at the service. However, we found one member of staff had started work before the second part of the DBS had been completed and this person’s recruitment file did not contain a risk assessment in accordance with the providers recruitment and selection policy. We discussed what we found with the care manager who told us this was an oversight. The provider used an external company to provide their staff induction. We reviewed staff induction records and could not be assured the services induction fully aligned with the Care Certificate. The Care Certificate is an agreed set of standards that define the knowledge, skills and behaviours expected of specific job roles in the health and social care sectors. Records showed and staff confirmed the external trainer had signed off observational practice without undertaking observations and induction documentation seem to suggest that important elements were not applicable for care staff. Such as privacy, communication, and respect. The nominated individual assured us that the induction was in addition to the mandatory training that all staff were required to complete. The provider monitored staff training on a training matrix. Records showed senior staff had received training in a variety of subjects relevant to their role. However, we could not be assured that care staff had received the same appropriate level of training. Following the inspection, the managing director provided additional information confirming the training care staff had received, which they assured us was in addition to their induction.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.