CQC report explained · a residential care home
What the CQC found at Oak Cottage
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2024
Rated Requires Improvement; safe care was Inadequate, with unsafe medicines management, poor risk controls and weak oversight.
This was an unannounced, focused inspection on 14, 19 and 22 December 2023. Inspectors looked only at Safe and Well-led. They reviewed care and medicine records, spoke with people, a relative and staff, and checked how the home was managed.
Inspectors found serious safety problems. Medicines were not reliably recorded or stored, staff were not always shown to be competent to give injectable medicines, and people's risks and needs were not properly assessed. Checks to reduce the risk of Legionella bacteria were also not completed properly.
The home was rated Requires Improvement overall. Safe was rated Inadequate. Well-led was rated Requires Improvement in the ratings table, although the detailed findings describe widespread and significant leadership shortfalls. The previous overall rating was Good in August 2017, but inspectors said quality and safety had significantly declined.
People felt safe
People told inspectors they felt safe living at the home and with the staff team.
“People told us they felt safe living in the home and with the staff team that supported them.” from the report
Clean accommodation
The home was satisfactorily clean, and people were supported to keep their own apartments clean and tidy.
“The home's environment was satisfactorily clean and people were prompted and supported to keep their own apartments clean and tidy.” from the report
Activities and family contact
People were supported to take part in activities they enjoyed, use the community and maintain family relationships.
“People were supported to maintain positive family relationships and family members visited without restriction. This was good practice.” from the report
Medicines were not managed safely
seriousRecords did not reliably show which medicines had been given, and stock could not be checked properly. Some staff could not give required medicines at night, and there was not enough evidence that staff were competent to give injectable medicines.
“There was no robust system in place to account for medicines.” from the report
Risks were not properly controlled
seriousPeople's health, safety and emotional needs were not adequately assessed or supported. This included risks linked to domestic appliances, changes in accommodation and emotional distress.
“Risks to people's health, safety and welfare were not adequately assessed, and mitigated against to prevent avoidable harm.” from the report
Legal rights and consent
seriousMental capacity assessments and best-interest decisions were not always completed. Conditions attached to some Deprivation of Liberty Safeguards authorisations were not followed.
“People's legal right to consent to and make decisions about their care and treatment had not been supported in line with the MCA.” from the report
Weak management checks
seriousAudits had not found the problems with medicines, care planning or Legionella monitoring. Provider and managerial oversight was not strong enough to protect people from avoidable harm.
“The governance arrangements were not robust. Managerial and provider oversight was poor and service delivery did not always promote good outcomes for people.” from the report
Agency staff information
needs fixingAgency and bank staff were regularly used to fill rota gaps. Not all agency staff had profiles showing their suitability, training, skills and competence.
“Not all of the agency staff had staff profiles in place for the manager and provider to be assured of their suitability.” from the report
- 01What changes have been made to record, store and check medicines, including injectable medicines?
- 02How are each person's risks, emotional needs and use of domestic appliances assessed and updated?
- 03How do you make sure mental capacity assessments, best-interest decisions and Deprivation of Liberty Safeguards conditions are completed and followed?
- 04What checks now identify problems with care plans, medicines, health and safety and Legionella monitoring?
- 05How do you check the suitability, training and competence of agency and bank staff, and how do you track each person's one-to-one support hours?
This was a focused inspection of Safe and Well-led only; the other key questions were not inspected and their previous ratings were carried forward when calculating the overall rating. This explanation was written from the published report of 29 February 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, February 2022
Inspected but not rated; inspectors found strong COVID-19 infection-control arrangements and appropriate visiting measures.
This was an announced, targeted inspection on 21 January 2022. Inspectors looked at infection prevention and control, visiting arrangements and whether COVID-19 staffing pressures affected the service.
The inspectors were assured that the home used testing, screening, PPE and social distancing effectively. Communal areas were hygienically clean, and there were plans for people who needed to self-isolate.
The home met the requirement for non-exempt staff and visiting professionals to be vaccinated against COVID-19. The service was inspected but not rated, so this report does not provide a full quality rating.
Regular testing
People living at the home and staff took part in regular testing to reduce infection risks.
“Staff and people using the service all undertook a regular programme of testing to keep everyone safe and free from infection.” from the report
PPE and hygiene
Inspectors saw suitable PPE in use and found that there was plenty available. Communal areas were clean and arranged to support distancing.
“We observed staff wearing appropriate PPE when supporting people and saw there was ample amounts of PPE available for staff, people using the service and also their visitors.” from the report
Plans for isolation
The home had procedures for managing COVID-19, including plans for people who needed to self-isolate and extra support for anyone who might find isolation difficult.
“There were management plans for those people required to self-isolate and additional support available for people who may struggle with isolation.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you currently test residents, staff and visitors for COVID-19?
- 02What PPE is available now, and how do you check that staff use it safely?
- 03How would you support my relative if they needed to self-isolate?
- 04How are visits currently arranged, and what screening is required before entry?
- 05What measures are in place if COVID-19 causes staff pressures?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19 staffing pressures; the service was inspected but not rated overall. This explanation was written from the published report of 8 February 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Oak Cottage
2 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- February 2024Requires improvementcurrent ratingSafe: InadequateEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2022Inspected but not ratedSafe: Inspected but not rated
- September 2017GoodSafe: GoodWell-led: Good
- September 2016
Registered with the Care Quality Commission on 21 September 2016.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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Most charge £980 to £1,260 a week. 83 can care for a couple. 10 years' experience on average.
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