CQC report explained · a nursing home
What the CQC found at Oakview Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some risks were not properly assessed or managed. Fire safety arrangements were not always adequate, and guidance about as-needed medicines was not always clear.
- Effective?
- Requires improvement
- The home did not always follow the principles of the Mental Capacity Act. Some capacity assessments were missing or had not been reviewed, and one deprivation of liberty application had not been followed up for three years.
- Caring?
- Good
- People and relatives described staff as kind and caring. Inspectors saw respectful interactions, although they also saw a urine sample taken from a catheter bag in a communal lounge, which did not protect the person's dignity.
- Responsive?
- Good
- People received personalised care and communication needs were recorded. However, some changes in people's needs were not reflected consistently in their care plans, and activities and interaction varied between units.
- Well-led?
- Requires improvement
- The home had audits and feedback systems, but its checks did not identify several important problems. The provider was responsive to the inspection findings and reported actions taken afterwards.
What inspectors found, May 2024
Rated Requires Improvement; inspectors found kind, responsive care but gaps in risk management, consent and oversight.
This was an unannounced inspection on 29 and 30 January 2024. Inspectors spoke with 12 people, 20 relatives and 10 staff. They reviewed care and medicine records, recruitment files, training records and checks on the home.
The overall rating fell from Good to Requires Improvement. Safe, Effective and Well-led were rated Requires Improvement. Caring and Responsive remained Good. Inspectors found people were generally treated kindly, had their needs responded to and could access healthcare, but some risks and records were not managed reliably.
The main problems involved incomplete risk assessments, fire safety, outdated or missing mental capacity records, unclear guidance for as-needed medicines and weak checks on the quality of care. The report says the provider took some action after the inspection, including updating care records and putting fire safety measures in place.
Kind and respectful staff
People and relatives spoke positively about staff. Inspectors saw good interactions and found that people were usually treated with dignity and respect.
“The staff are brilliant, they are very friendly and caring.” from the report
Enough suitable staff
Inspectors found there were enough staff to meet people's needs. Recruitment checks, including criminal record checks, had been completed.
“Processes in place ensured people were supported by suitable staff. A number of pre-employment background checks had been completed.” from the report
Healthcare support
Relevant healthcare professionals were involved in people's care. Relatives gave positive feedback about staff responding to health concerns.
“Recently [Name of Person] had a chest infection and the carer was worried. The carer called the GP out straightaway and later the same day [Person] had their antibiotics.” from the report
Feedback and complaints
The home had systems for recording complaints and actions taken. Residents' meetings and other feedback helped identify issues for action.
“There are minutes and they do action the points.” from the report
Risk assessments and fire safety
seriousCare plans and risk assessments contained conflicting or missing information. Fire risks linked to smoking, oxygen and flammable medicines were not always properly assessed, and staff did not always follow the required precautions.
“Management of risk was not always effective, placing people at increased risk of harm.” from the report
Consent and least restrictive care
seriousMental capacity assessments were not always completed or reviewed. The home did not have a reliable system for following up deprivation of liberty applications.
“We found the service was not working within the principles of the MCA.” from the report
Weak quality checks
seriousAudits failed to identify problems with risk records, care plan updates and as-needed medicine guidance. This meant the provider did not consistently find and correct important shortfalls.
“Systems were not always robust enough to demonstrate effective monitoring of the quality of the service.” from the report
Uneven activities and interaction
needs fixingThe quality of mealtime support and activities varied between the four units. On some units, people had limited interaction beyond care tasks, and staff did not always respond appropriately when one person became distressed.
“However, this was not reflected on all units. For example, multiple people were supported in their bedrooms and interaction was limited to care tasks.” from the report
One lapse in dignity
minorInspectors saw a urine sample taken from a person's catheter bag in a communal lounge while other people were present.
“Staff had not considered the person's dignity on this occasion.” from the report
- 01What specific changes have you made to fire risk assessments for people who smoke, use oxygen or have flammable medicines?
- 02How do you make sure care plans always contain current information about people's health conditions, risks and changing needs?
- 03How are mental capacity assessments reviewed, and how do you track deprivation of liberty applications until they are completed?
- 04How do staff decide when to offer as-needed medicines, and how is this recorded?
- 05What changes have you made to improve activities, mealtime support and interaction on the units where inspectors found a more task-focused approach?
This was an unannounced comprehensive inspection covering all five key questions; the previous overall rating was Good and the ratings for Safe, Effective and Well-led changed to Requires Improvement. This explanation was written from the published report of 9 May 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, April 2021
Inspected but not rated; inspectors were assured that infection prevention and COVID-19 safety measures were in place.
This was an announced, targeted inspection on 24 February 2021. It looked at infection prevention and control because of the coronavirus pandemic.
Inspectors were assured that the home managed visitors, PPE, social distancing, testing, admissions, hygiene and possible outbreaks safely. Staff had personal COVID-19 risk assessments and regular wellbeing conversations.
The home continued to allow visitors, with PPE and specific visiting areas. The overall service and the Safe area were inspected but not rated.
Visitor infection control
The home used a separate entrance and specific visiting areas to reduce the risk of infection spreading.
“The provider was following best practice guidelines in ensuring visitors to the home did not introduce or spread COVID-19.” from the report
PPE and hygiene
Staff followed PPE guidance, with extra PPE locations on each corridor. Handwashing and additional precautions were used where distancing was difficult.
“Staff were adhering to Personal Protective Equipment (PPE) guidelines and extra PPE locations had been set up on each corridor.” from the report
Staff wellbeing
All staff had a personal COVID-19 risk assessment, and the home held regular wellbeing conversations.
“The provider had ensured that all staff had received a personal COVID-19 risk assessment and conversations about their wellbeing were held regularly .” from the report
Wide infection controls
Inspectors were assured about admissions, testing, social distancing, hygiene and managing possible outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Inspectors raised no specific concerns in this report.
- 01Are the visitor entrance, PPE requirements and specific visiting areas still being used?
- 02How often are staff COVID-19 risk assessments reviewed?
- 03How are people using the service and staff being tested?
- 04What arrangements are in place to prevent or manage an infection outbreak?
- 05When was the home's infection prevention and control policy last updated?
This was a targeted inspection of infection prevention and control under Safe; the service was inspected but not rated, and the other areas were not covered. This explanation was written from the published report of 1 April 2021 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 Oakview Care Home
3 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- May 2024Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2021Inspected but not ratedSafe: Inspected but not rated
- January 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 27 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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