Oaktree Homecare Services Limited

We found 3 breaches of the legal regulations at this assessment in relation to the ineffective quality monitoring of the care provided. People were not always kept safe, and there were key shortfalls in ensuring people consented to the care and treatment they received from staff and managers. No one had come to harm as a result of these issues, but there was a potential risk some people may. There were two continued breaches in relation to keeping people safe and the governance of the service, from the last inspection. The registered manager and provider had resolved some, but not all of the issues found from the 2022 inspection.

The registered manager and provider did not have a system to identify and monitor people who had high or complex risks, who received care from the service. The registered manager did not have a culture of investigating when or why people requested that named individual member of staff should not visit and provide care to them. The lack of investigations when this happened placed people at potential risk of harm. Other incidents were not investigated effectively when staff brought these incidents to the attention of the registered manager and the office staff. When people had accidents, such as falls in their homes, these were also not investigated and checked by the provider effectively to ensure people were safe and their well-being was promoted.

Risk assessments lacked information to fully explore the risks which people experienced. The associated care plans to guide and direct staff practice about how to manage these risks, also lacked sufficient information to tell staff what they must do to manage the risks and what a change of need may look like for individuals.

There were enough staff to support people and on the whole people saw regular staff. However, we found 3 people who did not see regular staff and 1 member of staff had no travel time included in their work plan. Some people helped staff out by letting them leave their care visit early so staff had enough time to get to the next care visit. The registered manager and provider did not analyse the care visit data to check and identify issues like this and then take the appropriate action.

People were not always asked their consent for staff to take photos following incidents, and when care records were updated, people did not always consent to these. When relatives had legal powers to act in their loved one’s best interests, the extent and the circumstances of these powers were not clarified and documented to help staff and managers to protect people’s rights.

The issues found during this assessment were the result of at times ineffective governance of the service by the registered manager and provider. There was not a culture or sufficient understanding of auditing the quality of the care provided which meant it was not always possible to develop or implement agreed action plans to resolve the shortfalls found. There was not a culture of being curious, asking questions and looking at situations thoroughly to check people were safe. A culture had developed of people being nervous about raising issues about the care they received.

The provider and the registered manager welcomed our feedback and said they would take actions to make improvements. The registered manager contacted us later about some of the actions they had taken following our assessment.

We have asked the provider for an action plan in response to the concerns found at this assessment.