What the CQC found at Oak Cottage

People told inspectors they felt safe living at the home, although inspectors still found weaknesses in safeguarding systems.

“It is safe here, there is nothing like that to worry about.” from the report

Inspectors saw staff supporting people attentively. Staff had formed positive and friendly relationships with people.

“Staff were seen to be caring and attentive in their approach and had formed positive, friendly relationships with people.” from the report

People were able to see health professionals when needed. The home worked with GPs, nurses, physiotherapists and occupational therapists.

“We saw evidence of visits from various health care professional including GP's, community nurses, physios and occupational therapists.” from the report

The provider had improved window safety and was no longer in breach of the previous premises and equipment regulation.

“At this inspection enough improvement had been made and the provider was no longer in breach of this regulation.” from the report

Medicines were not always given or recorded safely. Care plans did not always contain enough guidance about people's health risks and distress.

“Although we found no person had experienced harm, risks to people were not always assessed and planned for, and medicines were not always managed safely.” from the report

Some incidents were not reviewed, investigated or referred to the local safeguarding authority. This meant timely action and learning could be missed.

“This meant people may not always be protected as timely action was not always taken to review, respond to and report incidents to keep people safe.” from the report

Staff were not always deployed in line with people's needs. Call-bell records showed regular delays of 20 minutes or more.

“Logs reviewed showed significant delays. People experienced delays regularly of 20 minutes or more.” from the report

Staff did not have enough training in dementia, mental health and other key areas. Formal competency checks and regular supervision were not consistently completed.

“The failure to ensure staff were suitably trained and supervised in their role was a breach of regulation 18” from the report

Some restrictions were used without the required legal authority. Capacity assessments, best-interest decisions, DoLS applications and advocacy referrals were not always completed.

“Some people had restriction in place without the legal authority to do so.” from the report

The home's audits did not identify important problems with medicines, staffing, weights and incidents. Management roles were unclear and there was no shared improvement plan.

“The provider continued to not operate effective systems, which were in place, to assess, monitor, and improve the service provided to people.” from the report