CQC report explained · a nursing home
What the CQC found at Oak Hall Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found clear risk assessments, safe medicines systems, suitable recruitment checks and effective infection control. Staff knew how to report safeguarding concerns and accidents were reviewed for recurring themes.
- Effective?
- Good
- Staff training and induction had improved, including shadowing experienced staff. The home worked with health professionals, supported nutrition and hydration, and followed the principles of consent and mental capacity law.
- Caring?
- Good
- This question was not covered by this focused inspection. The report says the inspection findings related to Safe, Effective, Responsive and Well-led.
- Responsive?
- Good
- Care plans recorded people's histories, interests and preferences. People were supported with activities, family contact, communication, complaints and end of life wishes.
- Well-led?
- Good
- Inspectors found stronger management, open communication and a robust audit system. People, relatives and staff said the home was more settled and improvements were being made.
What inspectors found, September 2021
Rated Good; inspectors found safe, personalised care and clear improvements since the previous inspection, with some paving and staffing issues to ask about.
This was an unannounced focused inspection on 20 August 2021. One inspector spoke with people living in the home, relatives, staff and health professionals. They reviewed care plans, staff recruitment files, medicines information, incident records and management records.
The home was rated Good overall. Safe, Effective, Responsive and Well-led were rated Good. Inspectors found that medicines, infection control, risk assessments, staffing and recruitment were managed safely. People had personalised care plans, choices about their daily lives and support to maintain relationships and interests.
The report says the home had improved from Requires Improvement at the previous inspection. The earlier breach about safe care and treatment was no longer in place. Inspectors also found improvements in training, care planning, auditing, communication and management.
Safer risk management
Risk assessments and care records gave staff clearer instructions about how to reduce known risks. The electronic system gave staff quick access to important information.
“There were clear improvements in the assessment of risks and the new electronic care system enabled staff to have immediate access to the information they needed to guide them.” from the report
Medicines
Medicines were stored, administered and monitored through established systems. Staff were trained and their competence was checked.
“The system alerted the registered manager when medication records were not completed fully, which could then be rectified straight away.” from the report
Personalised care
Care plans included people's lives, interests, preferences and ways of communicating. People were involved in reviews and had choices about meals, clothing and activities.
“Each person had a personalised care plan which reflected their likes and dislikes, their interests, social preferences, and personalities.” from the report
End of life support
People's wishes about their final days were discussed and recorded. Relatives gave very positive feedback about the support provided.
“My mother's end of life care was exemplary” from the report
Improved leadership
The report describes steady and sustained improvements in management, audits, communication and teamwork. The home was more settled than at the previous inspection.
“The registered manager was making steady and sustained improvements at the home and was clear about their responsibilities.” from the report
Paving repairs
needs fixingSeveral people had raised concerns about cracks in the garden paving. The manager said this was being addressed, but the report does not confirm that the repairs were complete.
“although several people had raised concerns about cracks in the paving needing repair.” from the report
Recent staff turnover
minorSome relatives had been concerned about staff turnover and occasions when nurses were stretched. Inspectors found enough staff on the day and noted that the situation was improving.
“Some relatives had shared with us their concerns about the turnover of staff in recent months, but commented that it was improving.” from the report
- 01Have the cracks in the garden paving now been repaired, and how do you check that outdoor areas are safe?
- 02What are the current staffing levels on each shift, and how do you cover sickness or staff shortages?
- 03How often are care plans and risk assessments updated, and how are families involved in reviews?
- 04How do you check that medicines records are completed accurately every time?
- 05What changes were made after the previous Regulation 12 breach, and how do you know those changes are continuing?
This was a focused inspection covering Safe, Effective, Responsive and Well-led; Caring was not covered on this occasion and the inspection was also carried out to check improvements after the previous breach. This explanation was written from the published report of 11 September 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.
What inspectors found, January 2020
Rated Requires Improvement; inspectors found kind care, but risks, medicines, personalised care and oversight were not always managed safely.
This was the home’s first inspection since it registered with CQC. Inspectors visited without notice on 6 November 2019. They spoke with people, relatives and staff, and checked care plans, medicines records, accident records, policies and audits.
The home was caring, with people describing staff as kind, respectful and supportive. Staffing levels, recruitment checks, infection control, safeguarding and referrals to healthcare professionals were also found to be satisfactory.
However, some important safety systems were not reliable. Staff did not always follow risk assessments, the call bell system was not used correctly, and medicines had not always been administered or recorded safely. Staff training was incomplete, care plans and activities were not personalised enough, and audits had missed problems.
The overall rating of Requires Improvement means the home was not consistently providing good-quality care. CQC found one legal breach relating to safe care and treatment and required the provider to submit an action plan and improve.
Kind and respectful staff
People and relatives spoke positively about staff’s kindness. Inspectors observed warm interactions and found that people’s dignity and privacy were respected.
“People and relatives told us staff were kind and compassionate.” from the report
Safe staffing and recruitment
Inspectors found enough staff on the day of the visit. Recruitment files showed checks such as references, employment history and DBS checks had been completed.
“There were sufficient staffing levels to meet people's needs.” from the report
Learning from accidents
The home reviewed accidents and introduced measures such as sensor equipment and hourly observations. The number of accidents and incidents fell from 30 to 12 within two months.
“By taking preventative action and learning lessons, the amount of accidents and incidents occurring had fallen from 30 to 12 within two months.” from the report
Infection control
Staff used gloves and aprons appropriately, and inspectors found the home clean. Cleaning and laundry arrangements helped separate clean and dirty items.
“Staff adhered to infection control practices which kept people safe from the risk of infection.” from the report
Involvement and choice
People and families were involved in care reviews and day-to-day decisions. Staff supported people to do as much as possible for themselves.
“We observed staff offering choices to people throughout the day.” from the report
Risk instructions were not followed
seriousStaff did not consistently complete repositioning or bowel charts required by people’s risk assessments. This left people at risk of pressure sores or constipation-related health problems.
“Risk to people were appropriately recorded but not always managed correctly which left them at risk of harm.” from the report
Medicine records were unsafe
seriousStock counts did not match the medicine records. One person received a medicine twice after it had been removed from their record, and staff did not record the doses.
“One person was receiving a medicine that was no longer on their MAR.” from the report
Call bell problems
seriousStaff were not using the correct portable device, and a call bell alarm remained active for 27 minutes. People had said that call bells were not always answered quickly enough.
“Staff were not using the correct portable device to make them aware of call bells sounding in the areas of the service they were working in.” from the report
Mandatory training was incomplete
needs fixingOnly 17 of 42 staff had completed Mental Capacity Act training and 21 of 42 had completed safeguarding training. CQC recommended that all staff become fully up to date.
“Staff were not up to date with mandatory training required to fulfil their roles effectively.” from the report
Care plans and activities needed personalising
needs fixingCare plans included limited information about people’s life histories and did not include health care plans. Activities were limited at some times, especially mornings and weekends.
“Care plans required further work to make them more personalised.” from the report
Audits missed problems
needs fixingQuality checks had not identified issues with care plans, medicines and the call bell system. An earlier peer audit had identified a call bell problem, but it had not been resolved.
“Internal quality audits were not always thorough as they had not identified the issues we found on the day of our inspection.” from the report
- 01What changes have you made to ensure staff follow repositioning, continence and other risk assessment instructions?
- 02How do you now check that medicines match the current prescription and are recorded correctly?
- 03Has the call bell system been upgraded, and how do you monitor response times?
- 04What proportion of staff have now completed Mental Capacity Act and safeguarding training?
- 05How have care plans, dementia-friendly areas and activities been made more personal, including at weekends?
This was an unannounced planned inspection of the care home covering all five CQC questions and both the premises and care provided. This explanation was written from the published report of 17 January 2020 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 Hall Care Home
2 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- September 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2020Requires improvementSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2018
Registered with the Care Quality Commission on 15 November 2018.
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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