CQC report explained · a residential care home
What the CQC found at Oulton Manor
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Most risk assessments were up to date, but one did not reflect changed safety equipment. Inspectors also found gaps in fluid monitoring and records supporting the use of some safety equipment.
- Effective?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward, but that rating is not stated in the report text.
- Caring?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward, but that rating is not stated in the report text.
- Responsive?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward, but that rating is not stated in the report text.
- Well-led?
- Good
- The home was well managed. Audits were being used to identify and address problems, and people, relatives and staff were involved in giving feedback.
What inspectors found, July 2023
Rated Good overall, but Safe was Requires Improvement because some risk and consent records were incomplete.
This was an unannounced focused inspection. Inspectors visited on 29 June 2023 and reviewed records, medicines, staffing and how the home was managed. They spoke with 10 people, 5 relatives and 9 staff.
The overall rating improved from Requires Improvement to Good. The home had made enough progress since the previous inspection to no longer be in breach of regulations. Inspectors found enough staff, safe recruitment, good infection control and positive leadership.
Safe was still rated Requires Improvement. Most risk records were up to date, but some records did not reflect current equipment or show how low fluid intake was acted on. Some mental capacity and best-interest records were also missing for safety equipment. These issues were being addressed.
Enough staff
Inspectors found enough staff to meet people's needs safely. People said they did not have to wait long for help, including at night.
“There were enough staff to meet people's needs safely.” from the report
Positive leadership
The new management team had recognised earlier problems and introduced changes. Inspectors found effective audits and greater involvement from people, relatives and staff.
“Auditing had been used effectively to identify and address issues.” from the report
Infection control
Inspectors were assured that the home had good systems to prevent and manage infection, including safe use of protective equipment.
“We were assured that the provider was responding effectively to risks and signs of infection.” from the report
Kind and attentive staff
People and relatives spoke positively about the staff. Inspectors saw staff being extremely caring and attentive.
“All people and relatives we engaged with spoke very positively about the staff who cared for them.” from the report
Risk records not fully updated
needs fixingOne person's risk assessment and care plan did not reflect a recent change in safety equipment. The management team acted immediately, but further updating was still needed.
“One person's risk assessment and care plan did not accurately reflect the change in safety equipment in use following a recent fall.” from the report
Fluid monitoring
needs fixingStaff recorded the amounts people drank, but inspectors could not see evidence that the charts were reviewed or that action was taken when intake was concerning.
“However, we did not see evidence that fluid charts were monitored to demonstrate what action was taken if a person's fluid intake was of concern.” from the report
Consent and best-interest paperwork
needs fixingSome records did not show that the correct mental capacity and best-interest process had been completed before sensor equipment or bedrails were used.
“2 people who had sensor mats or beams in place to alert staff of their movement, and a person who had bedrails in place, did not have mental capacity assessments or best interest decision documentation in place” from the report
- 01Have all risk assessments and care plans now been updated when people's safety equipment changes?
- 02Who checks fluid charts, how often are they reviewed, and what happens if someone is not drinking enough?
- 03Have mental capacity assessments and best-interest decisions been completed for people using sensor mats, beams or bedrails?
- 04What changes have been made to staffing patterns and management cover at weekends?
- 05How will the home show that the improvements identified after the previous inspection have been maintained?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 22 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.
What inspectors found, December 2022
Rated Requires Improvement, with Safe rated Inadequate because people faced risks involving care, medicines, staffing and safeguarding.
This was an unannounced focused inspection on 17 August, 22 August and 6 September 2022. Inspectors visited during the day and evening, spoke with people, relatives, staff and a health professional, observed care, and checked care, medicine, staffing and management records.
Inspectors found people were not always safe. Risks relating to falls, skin, mobility, nutrition and mental health were not always assessed or managed. Medicines were not always given or recorded safely, and staffing levels fell at a time when people still needed substantial support.
The home was well maintained and infection prevention systems were mostly effective. Staff were generally kind, but people could wait for care and comfort. Management systems had not identified or corrected important problems. The provider gave CQC an action plan and said it had increased night staffing and was working to improve temporary staff consistency.
Well-maintained accommodation
Inspectors found the building was spacious and well maintained. Relatives also gave very positive feedback about the home.
“A dedicated maintenance team ensured high standards were maintained. The home was luxurious and spacious.” from the report
Infection prevention
Most infection prevention systems were found to be effective, including arrangements for visitors, admissions and managing outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Kind staff
Inspectors saw that staff were generally kind and caring. Relatives also spoke positively about care staff and team leaders.
“We saw staff were generally kind and caring, but they were rushed, and routines were often task orientated.” from the report
Mental capacity safeguards
The report says the home was working within the Mental Capacity Act principles. Necessary legal authorisations and related conditions were in place where required.
“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place” from the report
Risk assessments and follow-up
seriousCare records did not always identify or manage risks such as falls, poor skin condition, mobility, nutrition and mental health. Incidents were recorded, but changes were not always made to prevent them happening again.
“Risks relating to people's skin integrity, mobility, nutrition and mental health were not always assessed and monitored effectively.” from the report
Medicines were not always safe
seriousSome medicines were given at the wrong time or without enough recording to show they were given as prescribed. Medicine care plans were not always current.
“Some people were prescribed medication which had to be given at specific times in order to be effective, such as for Parkinson's disease and pain relief.” from the report
Staffing levels
seriousThere were periods when there were not enough staff, particularly after 7pm. People waited for help and communal areas were sometimes left without staff supervision.
“However, at 7pm the staffing levels significantly reduced. During the day there were 14 staff to support 67 people over three dedicated units but after 7pm there was only seven staff.” from the report
Safeguarding and belongings
seriousThe provider did not always take effective action after safeguarding events. Relatives and staff also reported missing personal items and concerns about clothing, without evidence of inventories.
“The provider failed to demonstrate people were safeguarded from abuse and neglect. This placed people at risk of harm.” from the report
Weak management checks
seriousAudits and other systems were in place but had not found the problems inspectors identified. Records were not always accurate or up to date, and earlier recommendations had not been completed.
“Systems were in place, but they had been ineffective in ensuring the provider was compliant with regulations.” from the report
PPE practice
minorInspectors saw examples of staff not wearing face coverings correctly. This was discussed with the manager, who said it would be addressed.
“We were somewhat assured that the provider was using PPE effectively and safely.” from the report
- 01What changes have you made to night staffing since the inspection, and how do you check that there are enough staff on each unit?
- 02How do you now make sure medicines are given at the correct time, including medicines that must be taken before food or at specific times?
- 03How are falls, changes in health, nutrition, skin condition and distressed behaviour recorded, reviewed and acted on?
- 04What system do you use to safeguard residents' jewellery, clothing and other personal belongings?
- 05What actions from the CQC improvement plan have been completed, and what evidence can you show that your audits now identify problems?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from the previous inspection and are not stated in this report. This explanation was written from the published report of 30 December 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 Oulton Manor
4 rated inspections over 6 years: the service has held its Good rating throughout.
- July 2023Goodcurrent ratingup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2022Requires improvementSafe: InadequateWell-led: Requires improvement
- June 2021Inspected but not ratedSafe: Inspected but not rated
- April 2020Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- July 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Good
- July 2019
Registered with the Care Quality Commission on 22 July 2019.
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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