CQC report explained · a nursing home
What the CQC found at Oak Grange
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, November 2023
Rated Requires Improvement; inspectors found kind staff and positive food and activities, but serious gaps in staffing, risk management, care records and oversight.
This was an unannounced inspection carried out over five visits in July and August 2023. Inspectors spoke with 14 people, 13 family members, 23 staff and three visiting health and social care professionals. They also reviewed care plans, medicine records, staff files and management records.
The home was not always safe or well managed. There were not always enough staff, people experienced long waits for call bells, and risks from falls were not consistently managed. Some safeguarding procedures were not followed, medicine records contained inaccuracies, and information for the fire service was not fully accurate.
Care plans were not always updated when people's needs changed. The home did not always follow the law about consent and deprivation of liberty. Inspectors found kind and caring staff, positive comments about food, and activities taking place, but rated all five areas Requires Improvement. The previous overall rating was Good, published in December 2021.
Kind and respectful staff
Most people and families had something positive to say about the staff. Inspectors saw staff listen to people, act on what they said and protect their privacy.
“Nursing and care staff were seen to be kind and caring in their approach.” from the report
Food and nutrition
Inspectors found that people's nutritional needs were being met. Staff knew people's dietary needs and preferences, and comments about the food were generally positive.
“The nutritional needs of people were being met. Staff were aware of people's dietary needs and preferences.” from the report
Activities
People had opportunities to take part in activities and pastimes. Inspectors saw activities happening on each day of the inspection.
“We observed people engaging in a range of activities on each day of our inspection” from the report
Infection control
Inspectors were assured that systems and practices were in place to prevent and manage infections, including COVID-19.
“Effective systems, policies, procedures, and practices were in place to ensure people were protected from infection including COVID-19.” from the report
Working with health professionals
A visiting doctor and other health professionals gave positive feedback about the home's cooperation and care.
“A visiting doctor told us that managers and staff worked collaboratively with them to ensure people's health care needs were met.” from the report
Staffing and response times
seriousThere were not always enough suitably skilled staff. People reported long waits for call bells, and rotas showed staffing below the home's stated target on several days.
“People told us that they had to wait long periods of time for staff to answer the nurse call bell” from the report
Falls and other risks
seriousFalls risks were not always assessed or managed effectively. Measures in care plans were not always followed, leaving people at risk of avoidable harm.
“Measures to reduce the risk of falls were not always effective, leaving vulnerable people at risk of injury and harm.” from the report
Safeguarding
seriousAn unexplained bruising incident was not reported to the local safeguarding authority as required. Some staff were unclear about safeguarding reporting and whistleblowing procedures.
“Records showed that a vulnerable person had suffered unexplained bruising, however, this had not been reported to the local adult safeguarding authority” from the report
Care records
needs fixingCare plans did not always contain important information or reflect changes in people's needs. Inspectors continued to find recording errors and omissions during the inspection.
“Care plans did not always accurately reflect people's needs and were not always reviewed and revised when needs changed.” from the report
Consent and restrictions
seriousThe home had not always completed mental capacity assessments or applied for deprivation of liberty safeguards in good time for people who might not be safe to leave alone.
“The provider was not always working within the principles of the MCA.” from the report
Complaints
needs fixingFour relatives reported complaints about care, including staffing. Only one said they had received a satisfactory response.
“The three relatives who raised concerns about staffing levels told us that their complaints had not been taken seriously” from the report
- 01What staffing levels are now in place on each nursing care community during the day and at night?
- 02How are falls risks, pressure alarm mats and other safety measures now checked and acted on?
- 03How do you make sure care plans are updated promptly when a person's needs, medicines or risks change?
- 04How do you complete mental capacity assessments and apply for Deprivation of Liberty Safeguards when needed?
- 05What action has been taken on complaints about staffing and how are responses now checked?
The inspection began as a focused review of Safe, Effective and Well-led, but was broadened to include all five key questions and became a comprehensive inspection. This explanation was written from the published report of 18 November 2023 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, December 2021
Rated Good; inspectors found kind, personalised care, but identified some staffing and record-keeping issues.
Inspectors visited on 23 and 26 November 2021. They spoke with five people using the home, nine family members and three staff. They also reviewed care records, medicines, training, recruitment and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People were treated with kindness and dignity. Care plans reflected people's needs, choices and preferences. Families said communication was good and complaints were dealt with in a timely way.
There were some issues to put right. Staffing on one unit had fallen short as people's changing needs had not been highlighted. This was addressed on the inspection day. Inspectors also found that thickening powder and some food and fluid records were not always stored or completed correctly.
Kind and respectful care
Inspectors observed positive interactions. People and relatives described staff as kind, caring and respectful.
“Staff treated people with kindness, compassion and dignity.” from the report
Personalised care plans
Care plans included people's choices, health needs, likes, dislikes and preferred ways to spend their day.
“Each person's care plan was written in a way which was meaningful for them.” from the report
Staff training
Staff had completed training for their roles, including end of life care, and people and relatives were positive about their skills.
“Staff were well trained and had completed training courses to enable them to fulfil their role.” from the report
Good communication and complaints handling
Relatives said they were kept up to date. The home had a complaints process and complaints were recorded and answered.
“Complaints were investigated and responded too in a timely manner.” from the report
Improved leadership
Management had quality checks and action plans. The well-led rating improved from Requires Improvement at the previous rated inspection.
“This key question has improved to good.” from the report
Staffing levels
needs fixingStaff identified a shortfall on one unit, and some relatives felt staffing was low at night and weekends. Staffing was increased on the day of the inspection, but the home was still recruiting for vacancies.
“Some people felt that staff numbers were low at night and at weekends.” from the report
Thickening powder records
needs fixingThickening powder used to reduce the risk of choking was not always stored or recorded correctly. The manager said this would be corrected immediately after the inspection.
“Thickening powder used to stop aspiration and choking was not always stored and recorded correctly.” from the report
Food and fluid records
needs fixingSome wellbeing, fluid and diet charts were not being completed correctly. The manager acted during the inspection to improve the accuracy of these records.
“The registered manager took action during the inspection to ensure all staff correctly updated fluid balance and diet charts to help provide accurate records of people's needs.” from the report
- 01How do you check staffing levels on each unit, particularly at night and weekends?
- 02How do you make sure changing care needs are identified promptly and lead to changes in staffing?
- 03What has been done to ensure thickening powder is stored and recorded correctly?
- 04How do you check that food, fluid and diet charts are completed accurately every time?
- 05What refurbishment and maintenance work is planned, and when will it be completed?
This was a comprehensive inspection covering all five key questions; the February 2021 inspection was targeted and not rated, while the previous rated inspection in 2019 found the service Good overall but Requires Improvement for Well-led. This explanation was written from the published report of 11 December 2021 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 Grange
5 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- November 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- December 2021GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2021Inspected but not ratedSafe: Inspected but not rated
- July 2019Goodstayed GoodSafe: GoodWell-led: Requires improvement
- April 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014Inspected but not ratedSafe: Inspected but not ratedEffective: Inspected but not ratedCaring: Inspected but not ratedResponsive: Inspected but not ratedWell-led: Inspected but not rated
- July 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- May 2012
Registered with the Care Quality Commission on 21 May 2012.
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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