CQC report explained · a residential care home
What the CQC found at Oxbridge House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were identified and managed, staffing was sufficient, medicines were stored safely and infection control arrangements were effective. They recommended improvements to the medicine policy for social leave and records of annual health reviews.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward.
- Well-led?
- Good
- Inspectors found effective quality checks, clear action plans and stronger leadership involvement. People and staff said they felt listened to and involved.
What inspectors found, January 2023
Oxbridge House was rated Good; inspectors found safe, well-led care, but medicine policies and annual health review records needed improvement.
This was an unannounced focused inspection. Inspectors visited on 14 December 2022, 15 December 2022, 20 December 2022 and 03 January 2023. They spoke with people living in the home, relatives and staff, toured the home, and checked care, medicine and management records.
The home was rated Good for Safe and Well-led. Inspectors found enough trained staff, safe medicine storage, effective infection control, suitable risk plans and better checks on quality and safety. They also found a warm atmosphere, positive relationships and people involved in choices about meals and activities.
There were still two areas to improve. The home did not have a policy covering social leave and did not keep records showing that annual health reviews and physical health monitoring had taken place. CQC recommended that the home improve its oversight of these matters.
This was a focused inspection to check improvements after the previous Requires Improvement rating. The home was no longer in breach of the regulations identified at the last inspection. The ratings for Caring, Effective and Responsive were not reassessed and carried over from the previous inspection.
Enough consistent staff
There were enough staff during the day and night, including for one-to-one support. Inspectors found good staff retention and a consistent team.
“There were enough staff to provide support throughout the night and day as well as one-to-one support.” from the report
Safer medicines systems
Medicines were stored securely, staff had competency checks and audits were used to identify and act on problems. People could receive medicines in locations they preferred.
“Medicines were stored securely with the appropriate temperature checks taking place.” from the report
Positive atmosphere
Inspectors found a warm and supportive culture, with positive relationships between people, relatives and staff.
“There was a positive culture at the service which created a warm, relaxed and supportive atmosphere.” from the report
People involved in decisions
People attended regular meetings and were supported to choose meals and activities.
“We observed people choosing meals and activities throughout our visits.” from the report
Improved quality checks
Regular audits identified shortfalls and included action plans. The provider also received regular reports to monitor the home.
“Audits had been completed regularly by the acting manager and regional manager and were effective in highlighting any shortfalls.” from the report
Medicine policy for social leave
needs fixingSocial leave was not being managed in line with guidance, and staff did not have a policy to follow. CQC recommended that the home develop one.
“Social leave was not managed in line with guidance and the service had no policy in place for staff to refer to.” from the report
Records of health reviews
needs fixingStaff said annual health reviews and physical health monitoring took place, but the home had not kept records to show this. A tracking system had only just started during the inspection.
“The service did not keep a record of these reviews taking place.” from the report
- 01What policy now covers social leave and how do staff use it?
- 02How are annual health reviews and physical health checks recorded and followed up?
- 03What changes were made after the previous inspection's concerns about medicines, risk assessments and quality checks?
- 04How are people involved in choosing their meals, activities and appointments?
- 05How do you make sure there are enough staff for planned one-to-one support?
This was a focused inspection of Safe and Well-led, including infection control; the ratings for Effective, Caring and Responsive were carried over from the previous inspection. This explanation was written from the published report of 19 January 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, June 2021
Rated Requires Improvement; inspectors found gaps in medicines, risk checks, records and management oversight.
This was a focused inspection on 25 May 2021. Inspectors looked mainly at Safe and Well-led, including infection control. They spoke with people, relatives and staff, checked the building, and reviewed care, medicines, recruitment and management records.
The home had enough staff and safe recruitment processes. People told inspectors they felt safe, and inspectors found people were protected from abuse. Infection control arrangements were also judged satisfactory.
However, medicines records did not show clearly that medicines were given as prescribed. Some risks were not assessed, fire drill records were incomplete, and care records contained irrelevant information. Audits had not found these problems.
The overall rating fell from Good at the previous inspection in 2017 to Requires Improvement. This inspection found breaches of Regulations 12 and 17, and CQC asked the provider for an action plan and said it would monitor progress.
People felt safe
People told inspectors they felt safe and secure. Staff understood how to recognise and report abuse.
“People were protected from the risk of abuse. Staff demonstrated a good understanding of recognising the signs of abuse and how and where to report it.” from the report
Enough staff
Inspectors found there were enough staff to meet people's needs. Recruitment checks were also described as safe.
“There were enough staff to meet people's needs.” from the report
Choice and community access
People had person-centred activity timetables and could choose daily activities, including using local community facilities and going further afield.
“People used the community and local attractions daily as well as going further afield.” from the report
Infection control
Inspectors were assured about infection prevention, use of protective equipment, testing, social distancing and visits.
“We were assured that the provider was using PPE effectively and safely.” from the report
Medicines records
seriousRecords did not show reliably that medicines were administered safely. Some medicines did not have the required administration records, and handwritten entries were incomplete.
“Records did not evidence medicines were administered safely.” from the report
Weak management checks
seriousAudits had not identified the problems inspectors found with medicines, risk management and fire drills. The medicine policy also needed updating for this home.
“Audit systems and processes had not identified the shortfalls we found.” from the report
Poorly tailored records
needs fixingCare records were cumbersome and included information that did not apply to the person. Some health and hospital passports also needed updating.
“Care records were cumbersome and repetitive and included information not relevant to the person.” from the report
Communication with relatives
needs fixingRelatives said they were not always kept informed about appointments, medicines or feedback they had given.
“I feel like I don't know anything, for example when his appointments are, I am kept in the dark and whether he is still on the same medication” from the report
- 01What has been changed to make sure every medicine has a complete and accurate administration record?
- 02How are individual health and welfare risks now assessed, recorded and reviewed when people's needs change?
- 03How are night-time fire drills carried out, and how are evacuation times and follow-up actions recorded?
- 04How have care records and health or hospital passports been checked to remove information that does not apply to each person?
- 05How will relatives be kept informed about appointments, medicines and the feedback they give?
This was a focused inspection of Safe and Well-led, including infection control; the other key question ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 9 June 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 Oxbridge House
4 rated inspections over 7 years: the service has held its Good rating throughout.
- January 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- December 2017Goodstayed GoodSafe: GoodWell-led: Good
- December 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 11 November 2010.
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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