CQC report explained · a residential care home
What the CQC found at Oak Tree House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- Inspectors found enough staff, updated risk assessments, appropriate safeguarding referrals, safe medicines management and good infection control. They recommended that relevant previous social care employers should be contacted for references.
- Effective?
- Requires improvement
- This question was not assessed during this focused inspection. Its previous rating was used when calculating the overall rating.
- Caring?
- Requires improvement
- This question was not assessed during this focused inspection. Its previous rating was used when calculating the overall rating.
- Responsive?
- Requires improvement
- This question was not assessed during this focused inspection. Its previous rating was used when calculating the overall rating.
- Well-led?
- Requires improvement
- Inspectors found improved care planning, staff meetings and quality checks, but leadership was inconsistent. Recruitment checks, safeguarding knowledge and systems for managing complex risks were not yet sufficiently reliable or embedded.
What inspectors found, January 2024
Oak Tree House is rated Requires Improvement; inspectors found safe care but inconsistent leadership and systems that were not yet fully embedded.
This was an unannounced focused inspection. Inspectors visited on 29 November and 5 December 2023, spoke with people, staff, relatives and managers, and checked care records, medicine records, staff files and quality checks.
The home was rated Good for Safe. People told inspectors they felt safe. Staffing, risk assessments, safeguarding, medicines, infection control and learning from incidents had improved. The provider was no longer in breach of the staffing or safeguarding regulations from the previous inspection.
The home was rated Requires Improvement for Well-led. Inspectors found mixed views about the registered manager's visibility and responsibility. Checks of recruitment and risk management were still not reliable enough, and improvements needed more time to become fully established.
The overall rating remains Requires Improvement. This was the second consecutive inspection with that rating. The ratings for Effective, Caring and Responsive were not assessed during this focused inspection and were carried over from the previous inspection.
People felt safe
People told inspectors they felt safe, and staff understood their individual risks and how to reduce them.
“People were supported by staff who knew them well and knew how to meet their needs and manage risks.” from the report
Safe medicines
Medicines were stored and given safely. Staff followed guidance for medicines given only when needed, including the principles of STOMP.
“Medicines were stored and administered safely. The principles of STOMP (stop over medicating people with learning difficulties) were applied when people were prescribed 'when required' medicines.” from the report
Improved care planning
Care plans had been reviewed with people who wished to take part, and people were taking part in more activities they chose.
“The provider had placed more emphasis on making care person centred and empowering people.” from the report
Learning from incidents
The provider had introduced processes to review accidents and incidents, identify learning and share it with staff.
“Where accidents and incidents occurred, the registered manager reviewed them and identified any learning, which was then shared with staff.” from the report
Leadership was inconsistent
needs fixingStaff and relatives gave mixed feedback about the registered manager's visibility and responsibility. Inspectors said the positive changes needed more time to become fully established.
“Staff and relatives were not always clear about the role of the registered manager and did not always find them to be visible.” from the report
Risk systems were not fully embedded
needs fixingInspectors could not yet be assured that risk systems would be sufficient when supporting people with complex needs and risks.
“Systems in place to manage risks had not yet been sufficiently embedded.” from the report
Recruitment checks had gaps
minorOne staff file did not show that a previous social care employer had been contacted. Other recruitment checks also did not always identify missing risk assessments.
“Quality checks of recruitment records did not always identify gaps.” from the report
Safeguarding knowledge needed improvement
needs fixingThe registered manager's understanding of where safeguarding referrals should be sent was not always correct. Other managers supported the service so referrals were submitted appropriately when needed.
“The registered manager's knowledge regarding safeguarding procedures was not always adequate.” from the report
- 01How are you making sure the registered manager is visible, takes responsibility and is available to families and staff?
- 02How do you check that risk assessments remain suitable if a resident's needs or risks become more complex?
- 03How do you make sure previous social care employers are contacted for references before staff start work?
- 04What action has been taken to improve the registered manager's safeguarding knowledge?
- 05What evidence can you show that the improvements identified by inspectors are now fully embedded?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried over from the previous inspection. This explanation was written from the published report of 18 January 2024 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, September 2023
Rated Requires Improvement overall, with an Inadequate well-led rating and serious concerns about staffing, lawful restrictions, personalised care and safeguarding.
Inspectors visited on 13 and 27 June 2023. They spoke with people, relatives, staff and healthcare professionals. They reviewed care records, medicine records, staff files and management documents.
The home was not always safe or effective. Staffing was not always sufficient, some clinical risks were not assessed, and people did not always receive their planned one-to-one support. Mental capacity assessments and legal authorisations were missing for some restrictions on people's freedom.
People were generally treated with dignity and supported to see family, but care was not always personalised. Activities were not reliably planned, communication guidance was not always followed, and staff did not always have the knowledge needed to support autistic people effectively.
The home was rated Requires Improvement overall. Safe, Effective, Caring and Responsive were all Requires Improvement, while Well-led was Inadequate. The previous overall rating was Good in March 2018. The provider must send an action plan, and CQC will monitor progress with the provider and local authority.
Medicines
Inspectors found that medicines were stored and administered safely. Records and protocols were in place, including for medicines given only when needed.
“People's medicines were stored safely in a secure cabinet in a locked cupboard.” from the report
Privacy and dignity
Staff understood how to protect people's privacy and dignity. People could choose their bedroom furniture and decoration.
“Staff understood how to preserve people's dignity and respect their privacy.” from the report
Family relationships
People were supported to see relatives and maintain important relationships. They could visit family homes or receive visitors at the home.
“People were supported to see their families and maintain relationships that were important to them.” from the report
Infection arrangements
Inspectors were assured about several infection prevention arrangements, including the use of protective equipment and responding to infection risks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Safeguarding
seriousSafeguarding referrals were not always made after incidents, and some referrals were sent to the wrong local authority team. This placed people at risk of harm.
“Safeguarding referrals had not always been made when incidents of abuse occurred.” from the report
Staffing and one-to-one support
seriousThere was only one staff member working alone at night despite known risks. Records and rotas did not clearly show whether planned one-to-one hours were being provided.
“Systems had not been established to ensure a sufficient number of suitably qualified, competent, skilled and experienced staff were deployed to meet people's needs safely.” from the report
Unlawful restrictions
seriousMental capacity assessments were missing where needed. DoLS applications or authorisations were not in place for all people who were restricted from leaving independently.
“This meant people were being unlawfully restricted and deprived of their liberty.” from the report
Personalised activities and care
needs fixingCare was not always delivered in line with care plans. Activities were not consistently planned and could depend on staffing and the needs of other people.
“This meant they did not always do activities they wanted to do.” from the report
Staff skills
needs fixingStaff did not always feel sufficiently trained to meet people's specific autism needs. Professionals also reported gaps in knowledge about autism and positive behaviour support.
“Staff did not always feel adequately trained to meet people's autism needs.” from the report
Leadership and checks
seriousQuality checks were not effective and did not identify important risks. The registered manager did not understand some safeguarding and CQC notification requirements.
“Systems had not been established to assess, monitor and mitigate risks to the health, safety and welfare of people using the service.” from the report
- 01How many staff will be on duty during the day and at night, and what backup is available in an emergency?
- 02How do you record and check that each person's planned one-to-one support is actually provided?
- 03Have mental capacity assessments and DoLS applications now been completed for everyone who needs them?
- 04What autism-specific and positive behaviour training have staff completed, and how is their competence checked?
- 05How are activities planned in advance and protected when staffing or other people's needs change?
This began as a focused inspection of Safe and Well-led following concerns, but it was widened to a comprehensive inspection covering all five key questions. This explanation was written from the published report of 19 September 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 Tree House
4 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- January 2024Requires improvementcurrent ratingstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2023Requires improvementdown from GoodSafe: Requires improvementWell-led: Inadequate
- March 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2015
Registered with the Care Quality Commission on 4 February 2015.
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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