CQC report explained · a residential care home
What the CQC found at Oak House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, June 2023
Oak House rated Requires Improvement; inspectors found kind care and enough staff, but serious problems with medicines, safeguarding, consent and management.
This was an unannounced focused inspection on 16 and 20 March 2023. Inspectors spoke with people, relatives, staff and health professionals. They observed care and checked care plans, medicine records, incident records and recruitment records.
The home was not always safe. Some people did not receive medicines when needed, and records for creams and other topical medicines were incomplete. Inspectors also found that safeguarding concerns were not always handled or reported properly.
People were not always supported in line with the Mental Capacity Act. Some decisions were recorded in a general way rather than made for the individual. Inspectors also found that people were not always offered choice or asked for consent.
The overall rating is Requires Improvement. Safe, Effective and Well-led were rated Requires Improvement. Caring and Responsive were not inspected in this visit, so their previous ratings were used for the overall rating. The home was already rated Requires Improvement at the last inspection.
Kind and familiar staff
People and relatives described staff as kind, caring and quick to respond. A consistent staff team knew people's needs well.
“People and their relatives told us staff were kind and caring and they felt safe at the service.” from the report
Enough staff
Inspectors saw enough suitably trained staff to meet people's needs promptly. One-to-one support was available when needed.
“There were enough suitably trained and qualified staff to meet people's needs in a timely way.” from the report
Good risk planning
Risk assessments and care plans gave staff clear guidance. Staff also shared updates about changes in people's needs.
“Detailed risk assessments were in place, and care plans gave clear guidance about how to manage risks.” from the report
Activities and health support
The activities programme was tailored to individuals and ran seven days a week. The home worked with health and social care professionals.
“This was extremely person centred and tailored to meet people's individual needs.” from the report
Medicines were not always safe
seriousSome as-needed medicines were not given as prescribed. Staff did not always record topical medicines, so it was unclear whether they had been given.
“People did not always receive their 'when required' medicines as prescribed, and the necessary protocols were not in place.” from the report
Safeguarding concerns were not handled properly
seriousSome staff said concerns about safety had not been acted on. Safeguarding concerns were not always recognised, investigated or reported to the local authority when required.
“Safeguarding concerns had not always been raised with the local authority when required.” from the report
Consent and rights
seriousBest-interest decisions were recorded in a general way for groups of people rather than made individually when needed. Inspectors also saw a person restrained without the appropriate legal authorisation.
“People were not always supported in line with The Mental Capacity Act 2005.” from the report
Weak management checks
seriousAudits did not find the problems with medicines, safeguarding, consent and people's rights. Some staff said they feared losing their jobs if they raised concerns.
“Quality assurance tools were not effective, and the providers oversight of the service did not ensure people's needs were met safely.” from the report
Required notifications were missed
seriousThe provider did not always notify CQC about safeguarding concerns, a serious injury or authorised DoLS applications.
“The provider had failed to submit notifications in line with legal requirements.” from the report
- 01How are you checking that every as-needed and topical medicine is given and recorded correctly?
- 02What is the current process for staff, residents and relatives to report safeguarding concerns, and how are these concerns escalated?
- 03How are individual Mental Capacity Act and best-interest decisions now recorded for each person?
- 04What legal authorisations are now in place for any restrictions, sensor mats or covert medicines?
- 05What evidence can you show that the new manager's quality checks have found and fixed the issues identified by CQC?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected, so their previous ratings were carried forward for the overall rating. This explanation was written from the published report of 8 June 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, July 2022
Oak House was rated Requires Improvement; care was kind and personalised, but risk records and quality checks were not reliable enough.
This was an unannounced routine inspection over 4 and 9 May 2022. Inspectors spoke with people, relatives, staff and visiting professionals. They observed care and checked care plans, accident records, medicine records and recruitment records.
People generally felt safe and praised the kind staff, activities and personalised care. Medicines were given safely, staffing levels were suitable, and people received help with healthcare, food and drink. The ratings for Effective, Caring and Responsive were Good.
Inspectors found that some risks were not properly assessed or recorded. Records of falls and other incidents were incomplete and were not always followed up. Quality checks had not found these problems quickly enough. The provider had plans for training and closer oversight, but these changes had not yet become established.
The overall rating and the ratings for Safe and Well-led were Requires Improvement. This was the first inspection of the newly registered service. The previous provider had also been rated Requires Improvement in 2019.
Kind, respectful care
People and relatives spoke positively about staff. Inspectors saw caring interactions and found that privacy, dignity and independence were promoted.
“Throughout the inspection we saw kind and caring interactions between people and staff, and that staff were attentive and helpful.” from the report
Personalised care plans
Care plans gave staff detailed information about people's preferences, needs and strengths. Staff were updated when people's needs changed.
“They contained detailed information about people's needs, preferences and strengths.” from the report
Safe medicines and staffing
Medicines were given as prescribed, and staff had suitable training and checks. People and relatives said there were enough staff and that call bells were answered promptly.
“Medicines were administered in a safe way at the time they were prescribed.” from the report
Good links with healthcare professionals
Staff contacted outside professionals promptly and followed their advice. People were supported to maintain their health and wellbeing.
“They provide me with the necessary information needed for an assessment and do follow my advice and guidance.” from the report
Missing risk assessments
seriousRisk assessments were not always in place for important risks, including nutrition, diabetes and skin damage. Inspectors found that one person had been exposed to risk while alone in the garden.
“Risk assessments were not always in place when required.” from the report
Falls and incident records
seriousSome records did not clearly describe what happened or show what action followed. This meant the home might not learn enough from incidents to prevent them happening again.
“This meant that when things went wrong, there was a potential for re-occurrence, because insufficient action had been taken to review, investigate or learn lessons.” from the report
Quality checks were not effective
needs fixingThe home's monitoring systems had not found or fixed the recording and risk-assessment problems quickly enough. Improvement plans had been made but were not yet embedded.
“Quality assurance systems were in place but were not always effective.” from the report
Complaints information
minorThe complaints procedure was difficult to read because it was in very small print. People and relatives were also unclear about how to complain.
“People and relatives were unclear about how to make a complaint.” from the report
- 01Which risk assessments are now in place for nutrition, diabetes and skin integrity, and how often are they reviewed?
- 02How are falls and other incidents now recorded, investigated and followed up?
- 03What monthly checks does the provider now carry out, and can you show how these checks have led to improvements?
- 04How are activities matched to each person's interests and needs?
- 05How can relatives make a complaint, and how will the home keep them informed about concerns or changes in care?
This was an unannounced inspection covering all five CQC questions, including infection prevention and control under Safe. This explanation was written from the published report of 1 July 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 House
5 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- June 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2022Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodWell-led: Requires improvement
- April 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2020
Registered with the Care Quality Commission on 18 November 2020.
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 £1,020 to £1,270 a week. 15 can care for a couple. 13 years' experience on average.
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