CQC report explained · a nursing home
What the CQC found at Oakwood House Residential and Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were supported in a clean and safe environment, with enough trained staff and safer medicines systems. Inspectors noted some remaining medicines issues, including limited instructions for covert medicines and concerns about stock levels.
- Effective?
- Requires improvement
- Care plans had improved but did not always give enough detail about distressed behaviour, hoisting or updated health advice. Mealtimes did not always offer suitable choices or a social experience, and staff did not consistently seek consent.
- Caring?
- Good
- Most staff treated people with dignity and respect. People were supported to keep in touch with relatives, use shared spaces and gardens, and have a say in matters such as bedroom decoration.
- Responsive?
- Good
- Care plans had been rewritten to reflect people's needs, and the home responded to changing health needs. People were supported with activities, community access and contact with family, although activities were reduced because of COVID-19 restrictions.
- Well-led?
- Good
- The ratings section gives Well-led as Good, although the detailed findings describe it as Requires Improvement. New audits, governance systems and action plans had led to improvements, but inspectors said these needed to become embedded and identify all concerns independently.
What inspectors found, October 2020
Rated Good overall; inspectors found major improvements, but effective care still needed improvement, including mealtimes, medicines and consistent support.
The inspection took place on 19 August 2020. It was a planned inspection following the previous Inadequate rating. Inspectors observed care, spoke with one person, seven staff, three relatives and a health professional, and checked care, medicines, safety and management records.
The home was clean and safe. Staff were available, trained and aware of safeguarding duties. Medicines were generally managed safely, infection control had been strengthened for COVID-19, and people were usually treated with kindness and respect. Care plans had been rewritten and activities and family contact were supported as far as possible during the pandemic.
The main weaknesses were in the mealtime experience, some medicines information, and the consistency of care plans and consent practice. The home had made significant improvements since the previous inspection, when it was Inadequate and in Special Measures. It was no longer in breach of regulations or in Special Measures, but inspectors said new quality systems needed to become established so improvements lasted.
Safer care and staffing
The home had enough staff to meet people's needs promptly. Staff had received safeguarding training and recruitment checks were carried out.
“All people and staff spoken with said there were sufficient staff on duty.” from the report
Improved care planning
Care plans had been extensively rewritten and generally gave staff useful information about people's preferences and needs.
“Since our previous inspection in October 2019 care plans had been rewritten and contained sufficient information for staff to provide effective care and support.” from the report
Kind and respectful care
Inspectors saw mostly positive relationships between staff and people. Relatives also gave positive feedback about the care and communication.
“Most staff demonstrated a positive rapport with people and engaged in social conversations which improved people's wellbeing and engagement.” from the report
Infection control
The home was clean and had strengthened its infection control arrangements during the COVID-19 pandemic.
“Infection control procedures had been enhanced to address the COVID 19 pandemic.” from the report
Mealtimes
needs fixingPeople were not always offered meaningful food and drink choices. The rooms were not set up as a social meal setting, and some people had to wait for a chair.
“People were not always supported to make effective choices as to what they would like to eat.” from the report
Medicines information and supply
needs fixingInstructions for some covert medicines were limited and had not been checked by a pharmacist. The home also did not always hold enough medicines to last until the next delivery cycle, although action had been taken to avoid missed doses.
“There was no evidence of input from a pharmacist.” from the report
Inconsistent care instructions
needs fixingSome care plans did not explain clearly enough how to support people with distressed behaviour or transfers. This meant people could receive different support from different staff.
“We observed that this resulted in people receiving different support from different members of care staff.” from the report
- 01What changes have been made to make mealtimes more social and to give every person suitable food, drink and portion choices?
- 02How are covert medicines reviewed by a prescriber or pharmacist, and how do you make sure medicines do not run out?
- 03How do care plans explain the right way to support each person when they become distressed or need hoisting?
- 04How do staff seek consent before moving someone, providing care or putting on protective equipment?
- 05What evidence shows that the new audits and quality systems have stayed effective since this inspection?
This was a planned inspection of all five key questions and the premises and care provided, with additional checks on infection prevention and control during the COVID-19 pandemic. This explanation was written from the published report of 7 October 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, November 2019
Rated Inadequate and placed in special measures; inspectors found serious problems with safety, medicines, staffing, care and leadership.
Inspectors visited unannounced on 20 and 29 August 2019. They observed care, spoke with a resident, relatives, staff and professionals, and checked care, medicines and management records.
They found an unclean and poorly maintained environment, unsafe medicine practices, too few suitably trained staff and weak risk reporting. Care records did not always give staff enough guidance, and people were not consistently offered choices or supported with activities.
Staff were not always respectful or socially engaging. The home’s checks and action plans had not fixed problems found at earlier inspections. The overall rating was Inadequate, with Safe, Effective, Responsive and Well-led also rated Inadequate. Caring was rated Requires Improvement.
Some positive activities
One group activity was well facilitated and gave people social and cognitive stimulation. The home also supported two people to keep in touch with relatives abroad by video call.
“The group provided social and cognitive stimulation for people who attended, and one person was supported by a family member.” from the report
Some respectful practice
Inspectors saw some staff protecting privacy and dignity, such as knocking on bedroom doors and helping people change into clean clothes.
“For example, staff supported people to their rooms to discuss health care needs, knocked on bedroom doors, and people were assisted to put on clean clothes after lunch.” from the report
Relatives felt people were safe
Relatives who spoke with inspectors said they believed their relatives were safe living at the home. Staff also knew how to raise safeguarding concerns.
“Relatives spoken with told us they believed their relative was safe living in the service.” from the report
Some medicines safeguards
Medicines were stored safely, and covert medication requests had been reviewed by a GP with a best-interest decision recorded.
“Covert medication requests were reviewed by the GP and a best interest's decision recorded.” from the report
Unsafe environment
seriousInspectors found several hazards, including blind cords that posed a ligature risk, exposed hot pipes, a broken light fitting and an insecure window handle.
“The cords to the vertical blinds presented a significant ligature risk.” from the report
Unsafe medicines
seriousThe home did not record the exact times for time-critical medicines. Records for medicines given when needed did not always match, and instructions were sometimes unclear.
“The service was not safely managing people's medicines.” from the report
Too few trained staff
seriousThere were not enough qualified nurses, and many staff had not completed key training. The manager had to cover night nursing shifts, limiting their management time.
“Failure to ensure sufficient numbers of suitably qualified staff is a breach of regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Poor cleanliness
seriousInspectors found dirty bathrooms and equipment, damaged shower chairs and cleaning that was not effective. Similar infection control concerns had been found at the previous inspection.
“The service was not being effectively cleaned.” from the report
Weak care planning
needs fixingCare plans were being rewritten without people's involvement and did not always explain how to meet individual needs. Some staff could not easily access the more detailed records.
“We are concerned that a lack of involvement in their care planning may mean that care plans were not truly centred on the person, reflecting their current needs and preferences.” from the report
Dignity and social contact
needs fixingStaff were often focused on tasks and did not always engage with people. Inspectors saw people referred to by room number and found that activities were not consistently offered.
“The majority of care staff interactions with people were task focused.” from the report
- 01How are you now recording and checking the exact times of Parkinson's medicines and other time-critical medicines?
- 02How many qualified nurses and trained care staff are currently on each shift, including at night?
- 03What has been repaired or replaced in the bathrooms, bedrooms and communal areas since this inspection?
- 04How are care plans now reviewed with residents and relatives, and how do staff access the full current plan?
- 05How are incidents, complaints and safeguarding concerns recorded, investigated and followed up?
This was an unannounced comprehensive inspection covering all five key questions, including both the premises and the care provided; the ratings were compared with the previous inspection published on 27 February 2019. This explanation was written from the published report of 26 November 2019 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 Oakwood House Residential and Nursing Home
5 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- October 2020Goodcurrent ratingup from InadequateSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Oakwood House Residential and Nursing Home →
- November 2019Inadequatestayed InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
Read what inspectors found at Oakwood House Residential and Nursing Home →
- November 2019Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
- February 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2018Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2017
Registered with the Care Quality Commission on 3 October 2017.
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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23 live-in carers within about an hour of Suffolk
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Most charge £1,020 to £1,260 a week. 17 can care for a couple. 7 years' experience on average.
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