CQC report explained · a residential care home
What the CQC found at Oak Tree Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found risks to health and care were not always identified or managed. Medicines were not managed safely, and actions intended to prevent repeat accidents were not always followed through.
- Effective?
- Good
- Staff had relevant training and formal support. People enjoyed meals, received support with nutrition and healthcare, and were supported to make choices, although some capacity decisions were not fully evidenced.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff knew people well, encouraged choices and supported independence and contact with relatives.
- Responsive?
- Good
- Care was usually planned around people's needs and preferences. People had activities and could raise concerns, although some care and communication plans were incomplete.
- Well-led?
- Requires improvement
- Checks did not always identify problems or secure improvement. Records were not always accurate, key information was not always shared, and several new systems were still at an early stage.
What inspectors found, January 2023
Rated Requires Improvement; inspectors found kind and responsive care, but serious weaknesses in safety, medicines and oversight.
This was an unannounced inspection over 18 and 25 October 2022. Inspectors observed care, spoke with people, relatives and staff, and checked care, medicine, recruitment and management records.
People were treated kindly and inspectors rated the home Good for effective, caring and responsive care. People generally enjoyed the food, received support from trained staff and had activities and contact with relatives.
However, inspectors found people were not always safe. Risks were not always managed, medicines records and storage checks were not reliable, and actions after accidents were not always completed. Staffing could also be stretched.
The overall rating was Requires Improvement. Safe and well-led were both Requires Improvement, meaning there was limited assurance about safety and inconsistent management. This was the first inspection of the newly registered service.
Kind staff
People and relatives gave consistently positive feedback about staff. Inspectors saw kind, respectful interactions and support for people's dignity and independence.
“People were always treated with kindness. Feedback was consistently positive from people who used the service and their relatives.” from the report
Good meals
People were offered meal choices and mealtimes were not rushed. Inspectors found food was well presented and people's nutritional needs were met.
“People had pleasant dining experiences and food was well presented. They were offered choices and mealtimes were not rushed.” from the report
Trained staff
Staff received training in important areas such as dementia, moving and handling, and food safety. Supervision records showed regular formal support.
“Training data showed 100% compliance for most courses.” from the report
Safe recruitment
The provider completed checks before staff started work and involved people using the service in recruitment.
“The provider carried out appropriate checks to make sure staff were suitable before they started working at the service.” from the report
Health risks were not always managed
seriousInspectors found examples involving pressure sore prevention, choking supervision and diabetes monitoring where planned safety measures were not followed or recorded.
“Risks to people were not always assessed and managed.” from the report
Medicine safety
seriousMedicine storage temperatures, covert medicines, as-required medicines, self-administration records and medicine patches were not managed reliably. Inspectors said this placed people at risk of harm.
“Medicines were not managed safely.” from the report
Weak oversight and records
seriousManagement checks did not find important problems, and records about people's care were not always accurate or easy to follow. This made it difficult to know whether care had been delivered safely.
“Systems to assess, monitor and improve the service were not sufficiently robust.” from the report
Staff could be stretched
needs fixingSome staff said they did not always have enough time, and inspectors saw people waiting for support. Staffing numbers had increased but the new ratio was not consistently met.
“Staff sometimes delivered care in a rushed way.” from the report
- 01What has changed to make sure each person's health risks, such as choking, pressure sores and diabetes, are followed in practice?
- 02How are medicine fridge temperatures, covert medicines, medicine patches and topical medicines now checked and recorded?
- 03How do you make sure actions after falls, accidents and incidents are completed and tested?
- 04What new care-recording and handover systems are now in use, and how do you check that staff are using them correctly?
- 05How many staff are on each unit at different times, and what happens when the planned staffing level cannot be met?
This was an unannounced inspection covering all five key questions, including infection prevention and control; it was the first inspection of the newly registered service. This explanation was written from the published report of 13 January 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 Lodge
4 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- January 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- August 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2015Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- May 2021
Registered with the Care Quality Commission on 6 May 2021.
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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