CQC report explained · a residential care home
What the CQC found at Oakleigh House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected by safeguarding procedures, risk assessments, safe recruitment and adequate staffing. Medicines, infection control, fire safety and accident monitoring were also found to be managed safely.
- Effective?
- Good
- People's needs were assessed before moving in, and staff received induction, training, supervision and appraisals. People were supported with nutrition, healthcare, consent and least restrictive care.
- Caring?
- Good
- Staff were kind, patient and respectful. People were involved in decisions, had privacy, and were encouraged to maintain their independence.
- Responsive?
- Good
- Care was personalised and people were supported with their preferences, relationships, activities and communication needs. However, care plan records were repetitive and inconsistent.
- Well-led?
- Good
- The registered manager and staff were described as supportive and open. Audits, meetings, surveys and partnership working were used to monitor and improve the service.
What inspectors found, March 2020
Rated Good; inspectors found safe, kind and personalised care, with care plans that needed clearer and more consistent records.
This was an unannounced inspection on 14 February 2020. One inspector spoke with three people, two relatives, two staff members, the registered manager and a healthcare professional. They also checked care plans, risk assessments, medicines records, staff files, audits and policies.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough trained staff, safe medicines systems, suitable risk assessments and good infection control.
People were treated kindly and respectfully. They were supported to make choices, stay independent, eat and drink well, attend health appointments and take part in activities and community life.
The main shortfall was in care planning records. The plans were person centred, but some paperwork was repetitive and inconsistent, making it harder to see which information was current. Inspectors made a recommendation for clearer documentation.
Safe staffing and medicines
Inspectors found enough staff to meet people's needs, with appropriate recruitment checks. Medicines were stored, administered and checked safely.
“There were adequate numbers of staff on the day of the inspection.” from the report
Choice and independence
People were supported to make choices about their care and daily lives. Staff encouraged independence and used the least restrictive approach possible.
“People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible” from the report
Kind and respectful care
Staff listened to people, respected privacy and dignity, and supported people to express their views and make decisions.
“People's privacy and dignity was respected.” from the report
Activities and relationships
People were supported to take part in activities they enjoyed, go out into the community and maintain important relationships.
“People were supported to follow their interests and maintain links with the wider community.” from the report
Improved leadership
The previous Well-led rating was Requires Improvement. Inspectors found that earlier concerns had been addressed and rated this area Good.
“At this inspection this key question has improved to Good.” from the report
Care records were hard to follow
needs fixingCare plans were person centred, but contained repetitive information and inconsistent formats. This made it difficult to identify which risk assessments were current and relevant. Inspectors recommended improving the documentation.
“However, we found care plans difficult to follow as they contained a large volume of paperwork which was often repetitive and lacked consistency.” from the report
- 01What changes have been made to make care plans shorter, clearer and consistent?
- 02How do staff check that the risk assessments they are using are the current ones?
- 03How will you record and communicate changes in a person's mental health, risks or support needs?
- 04How are people involved in decisions about their care, activities and daily routines?
- 05How do you check that staff remain competent to administer medicines safely?
This was an unannounced planned inspection covering all five CQC questions; all five ratings were assessed during this visit. This explanation was written from the published report of 18 March 2020 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, August 2017
Rated Good overall; inspectors found safe, kind and effective care, but said the home needed to improve its leadership and record checks.
This was an unannounced inspection on 6 July 2017. It was the first inspection under the current registered provider. The inspector spoke with four people living there, two care staff, the registered manager and five community professionals. They also checked care plans, medicines, staff files and management records.
The home was rated Good for Safe, Effective, Caring and Responsive. People said they liked living there and felt supported. Inspectors found enough experienced staff, medicines being given as prescribed, good links with health professionals, support to build independence, and care that respected people's choices, privacy and dignity.
The Well-led rating was Requires Improvement. Audits had not found missing or inaccurate records, altered dates, an incomplete staff reference and some medicines recording errors. The manager corrected some issues promptly and described plans to improve checks. Overall, the service was rated Good, but its management systems were not consistently reliable.
People felt safe
Inspectors found safeguarding procedures, risk assessments and safety checks in place. People said staff supported them safely in the home and community.
“People were protected by risk management and safeguarding approaches at the service.” from the report
Improving quality of life
The home supported people with health needs, activities and independent living skills. Inspectors found examples of people becoming more stable, confident and capable.
“There were consequently many examples of how people's quality of life had improved from using the service.” from the report
Respectful relationships
Consistent staffing and the small size of the home helped people build trusting relationships. People were involved in decisions and their independence was encouraged.
“People were involved in making decisions about their care, and their independence was promoted whilst maintaining good care and support where needed.” from the report
Personalised support
People had individual care plans, keyworkers and support for activities and goals that mattered to them. They could raise concerns and contribute to residents' meetings.
“People were provided with individualised care that they helped to plan and review.” from the report
Medicines guidance and records
needs fixingThere was no individual guidance explaining when each person's as-needed medicine should be offered or the maximum amount before seeking medical advice. A controlled drug delivery and a medicine stock count were also recorded incorrectly, although the manager corrected these matters.
“However, there was no individualised guidance on people's specific PRN medicines, to help clarify circumstances when the person might be offered them and what the maximum amount was before seeking GP advice.” from the report
Inaccurate or altered records
needs fixingSome records were incomplete or inaccurate. Two dates had been altered to make meetings appear more recent than they were, and some risk assessment scores were added incorrectly.
“One staff member's supervision record date and the date of an in-service care review had been altered to indicate they occurred more recently than meeting records indicated.” from the report
Recruitment checks
needs fixingA required written reference for a new staff member had not been obtained or recorded. The employment gap had also not been explored in the records.
“For the only new staff member working at the service, written references did not cover a recent care employment which would have been a good source of checking the applicant's suitability.” from the report
Overdue care review
minorCare reviews were up to date for three of the four people checked. One new person's review had not been updated for more than two months when inspectors looked at it.
“These reviews were up-to-date for three of four people we checked on, but had not been updated for over two months in one of the new people's cases.” from the report
- 01How do you now check that as-needed medicines have individual guidance, including when to offer them and the maximum dose?
- 02What checks are now in place to make sure medicines deliveries, stock counts and controlled drugs records are accurate?
- 03How do you make sure all staff references and employment history checks are completed and recorded before staff work alone?
- 04How often are care plans and goals reviewed, and how do you make sure no review becomes overdue?
- 05What changes have been made to the quality auditing system since this inspection?
This was an unannounced inspection of the overall service under Section 60 of the Health and Social Care Act 2008, covering all five CQC questions and providing the first rating under the current registered provider. This explanation was written from the published report of 17 August 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 Oakleigh House
2 rated inspections over 3 years: the service has held its Good rating throughout.
- March 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2016
Registered with the Care Quality Commission on 13 July 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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