CQC report explained · a residential care home
What the CQC found at Oaktree Lodge Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, November 2022
Oaktree Lodge Residential Home was rated Requires Improvement; inspectors found unsafe medicines management, infection risks and weak oversight, although improvements had been made.
Inspectors made an unannounced visit on 3 October 2022. They spoke with staff and relatives, observed people, and checked care, medicines, recruitment and management records.
The home was not always safe. Medicines were not always stored, applied or recorded correctly. Infection control problems remained, including the layout of the laundry and worn or damaged areas that were harder to keep clean. Inspectors found no evidence that anyone had been harmed.
There were enough staff and recruitment checks were in place. People were protected from abuse, staff understood their needs, and relatives said they felt people were safe. The home had also improved its accident reporting, risk assessments and emergency evacuation plans.
The overall rating stayed Requires Improvement, for the second consecutive inspection. Safe and Well-led were both rated Requires Improvement. The other key questions were not inspected and their previous ratings were used for the overall rating.
Enough staff
Inspectors found enough staff to meet people's needs. Recruitment checks were also completed to confirm staff were suitable.
“There were enough staff to support people, and staff were safely recruited.” from the report
People felt safe
Staff knew people well and understood how to protect them from abuse. Relatives told inspectors they felt their family members were safe.
“People were kept safe from the risk of avoidable harm or abuse.” from the report
Improved risk arrangements
Personal emergency evacuation plans were in place and up to date. Covers and risk assessments had also been added for previously identified hazards.
“At this inspection we found PEEPs were in place, detailed and up to date.” from the report
Open communication
Relatives said staff kept them informed about changes, incidents and care needs. Inspectors found the management team open and honest when things went wrong.
“There was effective communication with people, their families and other agencies when incidents occurred within the service.” from the report
Medicines
seriousMedicine guidelines were not always followed. Records did not always show safe application or what action was taken when storage temperatures went above the recommended level.
“Medicines were not always managed safely, or records did not always evidence this.” from the report
Infection control
seriousThe laundry layout risked contaminating clean clothes. Some sinks lacked suitable paper towel dispensers, and worn or damaged areas made cleaning more difficult.
“We found no evidence that people had been harmed, however improvements were required to protect people through infection control practices.” from the report
Building repairs
needs fixingSome fire doors did not close fully, and broken window restrictors, worn carpets and old bathrooms had not all been dealt with. Inspectors recommended that repairs be reviewed and prioritised.
“We recommend the provider comprehensively review the repairs and improvements required and prioritise these to best manage risks to the health, safety and welfare of people using the service.” from the report
Quality checks
seriousThe home's audits and governance systems had improved but were not yet fully embedded. They had not identified every medicine and premises problem.
“Improvements were needed to ensure checks were effective and governance systems were robust and embedded in practice.” from the report
- 01What has been changed since the inspection to make medicine storage, cream application and skin-patch records safe?
- 02How do you now respond when the medicine room or trolley temperature goes above the recommended level?
- 03Which repairs have been completed on the fire doors, window restrictors, carpets and bathrooms, and what remains outstanding?
- 04How are clean clothes kept separate from contaminated items in the laundry?
- 05Has the new manager now registered with CQC, and how are audits checking that previous problems have stayed fixed?
This was an unannounced focused inspection of Safe and Well-led, including infection control; the other key question ratings were carried over from the previous inspection. This explanation was written from the published report of 12 November 2022 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, March 2022
Oaktree Lodge Residential Home was rated Requires Improvement; inspectors found risks with medicines, the environment, infection control and quality checks.
Inspectors visited on 12 and 18 January 2022. They observed care and medicines being given, reviewed nine people's records and spoke with people, relatives, staff and managers.
The home was not always safe. Inspectors found medicines that were not securely stored, incomplete records for pain patches, dirty medicine cups, environmental risks and gaps in infection control. Some people also experienced delays or less consistent care when agency staff were used.
The home's systems for checking quality had not found these problems. The overall rating fell from Good at the February 2018 inspection to Requires Improvement. This inspection only rated Safe and Well-led.
People felt safe
People and relatives told inspectors they felt safe and happy with the care. Staff had safeguarding training and knew how to report concerns.
“People and relatives felt safe and happy about the care they received.” from the report
Recruitment checks
The home completed pre-employment checks before staff started work, including checks of identity, references and suitability to work with vulnerable people.
“People were supported by staff who had pre-employment checks completed.” from the report
Family communication
The provider held meetings with relatives and sent updates, including when visits were not possible.
“The provider undertook relatives' meetings and they sent regular updates in between.” from the report
Partnership working
The registered manager worked with health and social care professionals and other managers.
“The registered manager worked in partnership with health care professionals such as, district nursing staff, GP's, social workers and the safeguarding team.” from the report
Medicines
seriousMedicines were given from dirty disposable cups, some medicines were left accessible, and records for pain patches were incomplete. This created risks of cross infection, unsafe access and missed or unclear doses.
“We observed people having their medicines administered from dirty and contaminated disposable plastic cups.” from the report
Environmental safety
seriousInspectors found uncovered radiators, unsecured heavy furniture and trailing wires. These risks had not been properly assessed or reduced.
“People could be at risk from radiators that posed a risk of scalding people should they fall or lean against them.” from the report
Incident records
needs fixingNot all accidents and incidents were recorded, including incidents involving people leaving the home unsupervised. Records did not always show what action was taken to prevent a repeat.
“We identified not all incidents and accidents had been recorded within this log.” from the report
Agency staffing
needs fixingPeople and relatives gave mixed feedback about staffing. Some said agency staff did not know people well, and one late arrival affected people's morning routines.
“People did not always feel supported by staff who knew them well.” from the report
Quality checks
seriousThe provider's audits and monitoring had failed to identify several problems found by inspectors, including medicine, infection control, environmental and incident-recording issues.
“The provider had failed to ensure effective quality assurance systems were in place to identify shortfalls found during our inspection.” from the report
- 01What has been done to make sure medicines are locked away, refrigerated safely and recorded correctly, including pain patches?
- 02How have you dealt with the uncovered radiators, unsecured furniture and trailing wires identified by inspectors?
- 03How do you now record accidents, people leaving the home unsupervised and the action taken to prevent similar incidents?
- 04How many agency staff are currently being used, and how do you make sure they know each person's needs and arrive on time?
- 05What evidence can you show that your quality audits now identify problems with infection control, medicines and the environment?
This was an infection prevention assurance inspection that became a focused inspection of Safe and Well-led; the other three key-question ratings were not assessed in this report. This explanation was written from the published report of 19 March 2022 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 Oaktree Lodge Residential Home
4 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- November 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Oaktree Lodge Residential Home →
- March 2022Requires improvementSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Oaktree Lodge Residential Home →
- May 2021Inspected but not ratedSafe: Inspected but not rated
- April 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- September 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 10 January 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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