CQC report explained · a nursing home
What the CQC found at Oakview 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
- Risk assessments did not always contain enough detail to guide staff. Weekly weights were missed for some people, and pressure mattresses were not always set according to people's weight.
- Effective?
- Requires improvement
- Care information was split between electronic and paper records, creating a risk that staff might not review it. Some people who needed help with meals were left waiting, although the home later staggered mealtimes.
- Caring?
- Good
- People and relatives described staff as kind and caring. Staff supported people's dignity, choices, independence and emotional needs, although one incident involved private care information being discussed loudly.
- Responsive?
- Good
- Care was personalised and staff knew people's preferences. People were supported to maintain relationships, take part in activities and follow individual interests.
- Well-led?
- Requires improvement
- Audits did not identify several of the shortfalls found during inspection. Care records, incident reviews and staff meetings needed more complete information and stronger follow-up.
What inspectors found, July 2023
Oakview Lodge was rated Requires Improvement; inspectors found kind, personalised care, but gaps in risk management, staffing deployment and quality oversight.
This was the first inspection since the home registered. Inspectors visited without notice on 11 May and 13 June 2023. They spoke with people, relatives, staff and managers, observed care, checked six care records and reviewed quality checks.
People were treated kindly and their care was usually personalised. Inspectors found good support for relationships, activities, independence and personal choices. People and relatives generally gave positive feedback about staff and managers.
There were important gaps in safety and management. Risk assessments and care records did not always give staff enough guidance. Weights and pressure mattress settings were not always checked, some people waited for help, and some people needing help with meals did not receive it promptly.
The overall rating and the ratings for Safe, Effective and Well-led were Requires Improvement. Caring and Responsive were rated Good. The home must improve its systems and send the regulator an action plan.
Kind and respectful care
People and relatives said staff were kind and treated them well. Inspectors saw staff respond sensitively to emotional needs and support independence.
“People and their relatives said care staff were kind, caring and treated them well.” from the report
Personalised support
Staff used people's histories, interests and preferences to shape care. This helped staff respond to anxiety and support people with personal care.
“The engagement team completed a life story, which captured people's history and interests.” from the report
Activities and relationships
People could keep in touch with family and friends and take part in activities suited to their interests. The home also supported individual outings and special wishes.
“People were supported to maintain relationships, form new friendships, and pursue their own hobbies and interests.” from the report
Medicines and infection control
Inspectors found medicines were stored and recorded safely. The home was clean and had arrangements to prevent and manage infections.
“People medicines were managed safely, and people received these as the prescriber intended.” from the report
Risk information was incomplete
seriousSome risk assessments did not explain clearly enough what staff should monitor or do. This included risks linked to choking, malnutrition and self-harm.
“This meant the risk of possible harm to people was not fully mitigated as staff did not have all the information they needed to support people safely.” from the report
Safety checks were missed
seriousSome weekly weights were not recorded and pressure mattresses were not always set correctly. These gaps could mean changes in people's health or skin condition were not identified promptly.
“For example, some people were assessed needing to be weighed weekly. We found that they were not weighed in May 2023.” from the report
Quality checks did not find problems
seriousThe home's audits did not identify several issues found by inspectors. Incident reviews and staff meetings also did not consistently record learning or important themes.
“The audits carried out by the provider or registered manager did not identify the shortfalls we found during the inspection.” from the report
Care records needed more detail
needs fixingSome records were incomplete or split between paper and electronic systems. End of life plans also did not always explain what personalised support meant for the individual.
“Care records needed more information and detail for staff to have all the information they needed to support and keep people safe.” from the report
- 01How are you now making sure each person's risk assessments give staff clear instructions, especially for choking, malnutrition and self-harm?
- 02How do you check that weekly weights and pressure mattress settings are completed and recorded correctly?
- 03How are staff deployed during busy periods so people do not wait too long for the toilet, transfers or personal care?
- 04How do you make sure everyone who needs help with eating receives it promptly and gets a genuine choice of meal?
- 05What changes have been made to quality audits, incident reviews and care records since the inspection, and how do you know they are being sustained?
This was an unannounced first inspection covering all five key questions, including infection prevention and control; the service had no previous inspection rating. This explanation was written from the published report of 12 July 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 Oakview Lodge
2 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- July 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2021Inspected but not ratedSafe: Inspected but not rated
- January 2019GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2021
Registered with the Care Quality Commission on 22 July 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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