CQC report explained · a nursing home
What the CQC found at Oak Springs Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2018
Rated Good overall; inspectors found kind, safe care, but the home’s quality checks still needed improvement.
This was an unannounced inspection on 27 September and 1 October 2018. Inspectors spoke with people, relatives, staff and an external professional. They reviewed care records, medicines, recruitment files, complaints and other records, and observed the home.
The home was rated Good for safe, effective, caring and responsive care. Inspectors found safe medicines administration, suitable risk assessments, appropriate staff checks, kind care, person-centred records, activities and sensitive end of life support.
The well-led rating was Requires Improvement. Audits and checks had improved since the previous inspection, but they did not always identify issues with topical creams and thickened fluids. The provider was no longer in breach of the regulations found at the previous inspection, but CQC recommended further review of quality checks.
Kind and respectful care
Inspectors observed caring relationships and support that protected people’s dignity, promoted independence and encouraged choice.
“Staff provided kind, caring and compassionate support in a genuine and sincere manner.” from the report
Safe staffing and recruitment
Staffing levels were reviewed against people’s needs. Recruitment files contained identity checks, references, employment histories and DBS checks.
“Staff were safely recruited and appropriate pre-employment checks were completed.” from the report
Individualised support
Care records included detailed information about people’s lives, preferences and routines. Staff were familiar with this information.
“Records were tailored around the needs of the person and staff were familiar with the likes, dislikes, preferences and wishes of people they supported.” from the report
Activities and engagement
People were offered a varied programme of activities based on their interests and preferences. Relatives were also invited to some activities.
“Activities were stimulating and were tailored around the suggestions and interests of the people who lived at Oak Springs.” from the report
Medicine records
needs fixingSome medicine administration records had missing signatures. Records for topical creams were not used consistently across the three units.
“Medication stock balances were correct although we did find a number of missing signatures” from the report
Quality audits
needs fixingThe home’s audits did not always identify issues with topical creams and thickened fluids. CQC recommended further work on quality assurance.
“medication administration processes in relation to topical creams and thickened fluids were not always identified in the medication audits that were conducted.” from the report
Pictorial menus
minorInspectors noted that pictorial menus were not available for people to use when choosing food. The home said this would be reviewed and introduced.
“there was no availability of pictorial menus for people to choose their food from.” from the report
- 01How are you checking that medicine administration records have all required signatures?
- 02How do you now audit topical creams and thickened fluids across all three units?
- 03Have pictorial menus been introduced, and how do people who need them choose their meals?
- 04What changes have been made since CQC recommended a further review of the quality assurance systems?
- 05How do you make sure staffing levels continue to match residents’ changing care needs?
This was an unannounced inspection covering all five CQC questions and checking improvements since the August 2017 inspection. This explanation was written from the published report of 25 October 2018 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, October 2017
Rated Requires Improvement; inspectors found kind care, but unsafe medicines systems, fire doors and weak oversight remained.
Inspectors visited the home without notice on 14 August 2017. They looked at records, watched care and medicines being given, spoke with people, relatives and staff, and contacted other professionals.
The home had improved since its February 2017 inspection. Care plans and risk assessments were better, staff supervision had improved, and people generally described staff as kind and respectful. However, important problems remained with medicines, fire doors, call-bell response times, staff induction, dementia-friendly surroundings and management checks.
The overall rating was Requires Improvement. Caring was rated Good. Safe, Effective, Responsive and Well-led were all rated Requires Improvement. This means the home was not consistently meeting the required standard, and the provider was told to take action.
Kind and respectful staff
Inspectors saw staff speaking positively to people, listening to them and using encouraging language. People and relatives spoke well of the staff’s attitude and care.
“Throughout the inspection we saw staff engaging with people in a positive and caring manner.” from the report
Improved care planning
Care plans were more detailed and person-centred after admission. Risk assessments were regularly reviewed and supported by care plans.
“Practice in relation to care planning showed clear evidence of improvement.” from the report
Safeguarding awareness
Staff had completed safeguarding training and could explain what they would do if they suspected abuse or neglect.
“Staff understood their responsibility to keep people safe from abuse and mistreatment.” from the report
Complaints handled
The home had a complaints procedure and recorded written responses. It also acted on feedback, including producing an easy-read complaints procedure.
“Each had been dealt with in accordance with the relevant policy and included the production of a written response.” from the report
Medicines not safely managed
seriousMedicine administration records were inconsistent, some stock levels were not recorded properly, and treatment rooms regularly exceeded 25 degrees Celsius. These problems could put people at risk of missed, duplicated or less effective medicines.
“The system for recording the administration of records was neither consistent nor robust.” from the report
Fire doors remained unsafe
seriousSome fire doors did not close fully every time they were tested. The kitchen fire doors were still affected by airflow and the extractor fan.
“We saw that not all fire doors closed fully on each occasion they were tested.” from the report
Delays in care
needs fixingTwo-to-one personal care sometimes left only one staff member caring for up to 16 people on a unit. People and relatives reported waiting for care, and inspectors recommended a review of staffing needs.
“A family member commented that their relative had been kept, "Waiting for up to an hour for care.” from the report
Incomplete admission information
seriousSome pre-admission records were missing information, including capacity details, signatures or dates. This meant the home could not always establish before admission whether it could meet someone’s needs.
“This meant that the provider could not make an accurate determination whether Royal Oak Care Home could meet the person's needs before they arrived.” from the report
Weak management checks
needs fixingAudits found some issues but did not consistently identify significant problems or lead to timely action. There was also no registered manager in post.
“Audit processes had not consistently identified significant issues and had not always resulted in timely action by the provider.” from the report
Training and dementia environment
needs fixingNew staff had not been observed and assessed as competent after their two-day induction. Training records did not clearly evidence dementia training, and more work was needed on signage and communal areas.
“There was no evidence that they had been observed or that their competency had been assessed following their initial two day induction course.” from the report
- 01What has been done to ensure every medicine administration record is completed at the time medicines are given, and that medicines are stored below safe temperatures?
- 02Have all fire doors, especially the kitchen doors, been permanently repaired and tested? How often are they now checked?
- 03How do you decide whether staffing is sufficient when people need two staff for personal care, and what are the current call-bell response times?
- 04How are new staff observed and assessed as competent after induction, and how is dementia care training recorded?
- 05What information must be obtained before admission, and how do you make sure the home can meet each person’s needs before they move in?
This was an unannounced comprehensive inspection covering all five key questions and checking whether improvements from the February 2017 inspection had been made and sustained. This explanation was written from the published report of 13 October 2017 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 Springs Care Home
3 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- October 2018Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2016
Registered with the Care Quality Commission on 11 October 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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