CQC report explained · a residential care home
What the CQC found at Oak Lodge Residential Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Risk assessments, medicines management, staffing, recruitment and infection control were found to be suitable.
- Effective?
- Good
- People's needs were assessed and staff supported consent and best-interest decisions. People received suitable food and drink, had access to health professionals and were supported by trained staff.
- Caring?
- Requires improvement
- This question was not inspected during this focused inspection, so no new rating was given in this report.
- Responsive?
- Requires improvement
- This question was not inspected during this focused inspection, so no new rating was given in this report.
- Well-led?
- Requires improvement
- Management systems had improved, but some care records still lacked important information and signatures. New and agency staff needed better access to clear instructions about people's needs.
What inspectors found, May 2023
Rated Requires Improvement; inspectors found safe and effective care, but records and management checks still needed improvement.
This was an unannounced focused inspection on 4 April 2023. Inspectors spoke with people, relatives and staff, observed care, and reviewed care, medicines, staff and management records. They looked at Safe, Effective and Well-led.
The home was rated Good for Safe and Effective. People were protected from avoidable harm, medicines were given safely, staffing levels appeared sufficient, and staff had suitable training. People were asked for consent and supported with food, drink and access to health professionals.
The home was rated Requires Improvement for Well-led. Some care records were missing important instructions and some had missing signatures. Inspectors found that the home had improved since the previous inspection, but its overall rating was still Requires Improvement.
The previous overall rating was Inadequate. The home was no longer in breach of regulations and was no longer in Special Measures.
Safe care
People felt safe and staff understood how to protect them from avoidable harm. Risk assessments and emergency plans were in place.
“People felt safe and were supported by staff who knew how to protect them from avoidable harm.” from the report
Medicines
Medicines were stored and given safely. Records showed medicines were administered correctly and staff had training and competency checks.
“At this inspection we found people received their medicines safely and as prescribed.” from the report
Staffing and training
Inspectors found enough staff on duty during the day. Recruitment checks and staff training were in place.
“Our observations during the day, indicated there were enough staff on duty to support people with their care needs.” from the report
Food and health support
People had choices of food and drink and could access health professionals. Care plans were reviewed and staff understood people's health needs.
“People were supported by staff to have enough to eat and drink to keep them healthy.” from the report
Incomplete care records
needs fixingSome records did not contain all the instructions staff needed, including what to do when someone had a seizure. Some records also had missing signatures.
“We found further improvements were required to ensure records contained all the required information to ensure people's needs were met.” from the report
Support for new and agency staff
needs fixingRelatives and inspectors said new or agency staff needed more support and did not always have enough information recorded to guide their work.
“Staff we spoke with were knowledgeable about people's health conditions and actions to take to ensure their needs were met however new staff members or agency workers would benefit from having all the required information recorded in people's care records.” from the report
- 01How do you make sure every person's care record contains clear instructions for staff, including what to do during a seizure?
- 02How do you check that care records have been read and signed by the people involved?
- 03What extra supervision and training do new and agency staff receive before working on their own?
- 04How do you check that your quality audits identify and fix missing information promptly?
- 05What were the results of your latest checks on medicines, and how will you show that safe medicines practice is continuing?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and the report does not give new ratings for them. This explanation was written from the published report of 18 May 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, February 2023
Rated Inadequate and placed in special measures; inspectors found serious safety, consent and management failures.
Inspectors made an unannounced focused inspection on 27 June 2022. They spoke with people, relatives and staff, observed care, and checked care records, medicines, premises and management systems.
The home was not safe. Inspectors found unsafe equipment, unlocked hazardous substances, poor medicines storage and gaps in repositioning records. Some people did not receive medicines in line with their instructions, including pain-relief patches.
The home was rated Inadequate overall, Inadequate for Safe and Well-led, and Requires Improvement for Effective. The Effective rating stayed the same as at the previous inspection, while Safe and Well-led fell from Requires Improvement. The other two areas were not inspected and their previous ratings were used.
People felt safe with staff
People appeared relaxed around staff, and relatives said their loved ones were safe and comfortable.
“People were comfortable, relaxed and happy around care staff and staff understood how to keep people safe.” from the report
Enough staff were on duty
Inspectors observed enough staff during the day to support people's care needs. People and relatives also said staffing was sufficient.
“Our observations during the day, indicated there were enough staff on duty to support people with their care needs.” from the report
Food and drink support
Nutrition records were up to date, and staff knew people's food preferences, dietary needs and risks.
“People's care records contained up to date nutrition information for staff to follow.” from the report
Links with health professionals
The home worked with health professionals, including GPs, dentists and opticians, and staff monitored changes in people's health.
“The service worked very closely with other agencies and health professionals in order to meet people's specific needs.” from the report
Unsafe premises and fire equipment
seriousInspectors found exposed wiring, a loose call unit, a protruding nail and a broken door closure that could affect fire safety.
“In one person's bedroom a plug socket was damaged, it was taped up with internal wiring exposed and left in an unsafe state.” from the report
Medicines were not managed safely
seriousMedicines had been stored above the recommended temperature for nearly two months. Records for pain-relief patches and sharps management were also unsafe or incomplete.
“The provider had not ensured the proper storage and safe use of medicines.” from the report
Incomplete care records
seriousThere were unexplained gaps in repositioning records and missing information about people's health needs. This could mean staff did not follow the right care plan.
“We found numerous unexplained gaps in some peoples' repositioning charts.” from the report
Consent decisions were not recorded
seriousSome people who lacked capacity did not have decision-specific assessments and best-interest decisions recorded for bedrails.
“The provider had failed to ensure the principles of the MCA were followed as people did not always have their capacity assessed for specific decisions and best interests' decisions recorded as required.” from the report
Weak management checks
seriousAudits and maintenance checks had not identified serious problems found during the inspection. The provider showed inspectors a new audit system that was due to be introduced.
“Systems and processes to assess and monitor the quality and safety of the service were not robust.” from the report
- 01Have all damaged equipment, exposed wiring and the broken bedroom door closure been repaired, and when were these repairs completed?
- 02How are medicines now stored and checked, including medicine-room temperatures, pain-relief patches and sharps disposal?
- 03How do you check that repositioning is taking place and that records are completed without gaps?
- 04Have decision-specific capacity assessments and best-interest decisions been completed for everyone using bedrails?
- 05What new checks are now in place to find problems with care records, health needs and equipment before people are put at risk?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and previous ratings were used for the overall rating. This explanation was written from the published report of 1 February 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.
Every inspection of Oak Lodge Residential Home
6 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- May 2023Requires improvementcurrent ratingup from InadequateSafe: GoodEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2023Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementWell-led: Inadequate
- August 2019Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- July 2019Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2015Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- July 2011
Registered with the Care Quality Commission on 21 July 2011.
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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