CQC report explained · a residential care home
What the CQC found at Oxendon House Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Risks were assessed and monitored, staffing levels were considered safe, medicines were generally well managed, and infection control arrangements were in place.
- Effective?
- Good
- People's needs were assessed before they moved in, and staff had suitable training and supervision. People received support with food, drink and healthcare, and the home followed the Mental Capacity Act requirements.
- Caring?
- Good
- Inspectors saw warm and reassuring interactions. Staff treated people with dignity and respect, involved them in decisions where possible, and encouraged independence.
- Responsive?
- Good
- Care plans described people's individual needs, routines and preferences. Activities were available, but the activities coordinator had recently left and a replacement had not yet started.
- Well-led?
- Good
- Management and quality monitoring had improved. Audits were used to identify issues and track action, and the home submitted required notifications in a timely way.
What inspectors found, February 2023
Oxendon House Care Home was rated Good; inspectors found safe, kind and well-managed care, with some areas still being improved.
The inspection was unannounced and took place on 5 January 2023. One inspector and two Experts by Experience spoke with people, relatives and staff. They also observed care and checked care, medicine, staffing, training and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people were protected from abuse, risks were assessed, medicines were generally managed safely, and there were enough staff.
People were supported by trained staff who treated them with kindness and respect. Care plans were personalised, people received suitable food and healthcare support, and complaints were investigated.
The overall rating improved from Requires Improvement at the previous inspection, published in January 2022. The provider had made enough progress and was no longer in breach of Regulations 12, 17 or 18.
Improved oversight
The home had strengthened its quality checks since the previous inspection. Managers used regular audits to identify and address issues.
“Improved quality monitoring and auditing systems had meant the provider had made improvements in all areas which we highlighted during our previous inspection.” from the report
Kind and respectful care
People and relatives described staff as caring. Inspectors observed calm, attentive and reassuring interactions, including with people living with dementia.
“We observed staff interacting with people throughout this inspection and witnessed numerous positive, warm interactions between people and staff.” from the report
Personalised care
Care plans included detailed information about people's routines, preferences and communication needs. Staff understood how to provide care for each person.
“Care plans were personalised and described an accurate picture of the person and their individual needs.” from the report
Safe care arrangements
Inspectors found suitable systems for safeguarding, risk management, staffing, medicines and infection control.
“People were protected from the risk of abuse and neglect. Risks to people's health and safety were appropriately assessed, monitored and acted on.” from the report
Activities staffing
needs fixingThe activities coordinator had left and the replacement was not yet in post. Staff were providing activities as a team and trying to offer people individual time.
“The activities coordinator had recently left, and a new person had been recruited; however, they were not yet in post.” from the report
Mealtime experience
minorInspectors discussed that mealtimes could be improved. The manager planned audits to review this.
“We discussed with the registered manager the mealtime experience could be improved for people.” from the report
End of life planning
needs fixingPeople had basic end of life care plans with some detail about their wishes. The manager said more advanced care planning was being developed.
“People had basic end of life care plans in place that contained some detail on people's wishes.” from the report
- 01When will the new activities coordinator start, and how will you make sure people continue to receive individual and group activities?
- 02What changes are being made to improve the mealtime experience, and when will these be reviewed?
- 03How will you develop advanced care plans so that each person's end of life wishes are clearly recorded?
- 04How often are the new quality audits reviewed, and how are families told when an issue affecting care is found?
- 05What improvements were made to the call bell system, and how are response times monitored?
This was an unannounced inspection that rated all five key questions and included infection prevention and control; the previous inspection's Requires Improvement rating was reviewed and changed to Good. This explanation was written from the published report of 3 February 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, March 2022
Inspected but not rated; inspectors found some good infection-control practice but a breach of safe care and treatment rules.
This was an unannounced, targeted inspection on 13 January 2022. It focused on infection prevention and control, visiting arrangements, and whether staffing pressures affected the service.
The home had enough PPE, staff were observed using it correctly, and the home was visibly clean. People were supported with COVID-19 vaccinations and boosters, and end of life visiting was well supported.
Inspectors found important gaps. Essential carers were not tested in line with guidance, visitor screening was not being recorded, cleaning checks were not recorded, and some people admitted from hospital had not isolated for the full recommended period.
The overall service was inspected but not rated. Regulation 12 was breached because care and treatment was not consistently provided safely in relation to infection risks. The provider was required to send an action plan, which CQC said it would check.
PPE and hand hygiene
The home had adequate PPE supplies. Staff were trained and observed following PPE and hand hygiene guidance.
“Staff were observed to be wearing the correct PPE and following hand hygiene guidance during the inspection.” from the report
Clean environment
The home was visibly clean and had no unpleasant smells during the inspection.
“The home was visibly clean and free from malodour.” from the report
Vaccination support
People were supported to access COVID-19 vaccinations and booster doses. Staff were vaccinated in line with the regulatory requirement.
“People had been supported to access the vaccination and booster programme and all staff were vaccinated as per the regulatory requirement.” from the report
End of life visiting
Inspectors found that visits at the end of a person's life were well supported.
“End of life visiting was well supported by the service.” from the report
Testing and visitor screening
seriousEssential carers were not tested in line with government guidance. The home was also not using its COVID-19 screening tool before visitors entered.
“Essential care givers were not tested in line with the government guidance.” from the report
Infection-control records
needs fixingThe home did not have records to show that the visiting room and high-touch areas had been cleaned. Inspectors had raised the cleaning-record issue at the previous inspection, but found no improvement.
“We had raised this concern with the provider at our last inspection, however we found no improvement at this inspection.” from the report
Hospital admissions and policies
seriousSome people admitted from hospital had not isolated for the full recommended period. The provider also had not ensured that COVID-19 policies were in place or clear for staff.
“The provider had not ensured people were admitted to the service safely in line with the government guidance.” from the report
Visiting arrangements
minorThe home updated its visiting arrangements, but some relatives were not aware of the changes. CQC recommended that the provider continue to follow current government visiting guidance.
“However, some relatives we spoke with were not aware of the changes.” from the report
Checks on visiting professionals
needs fixingThe home did not keep records showing that visiting professionals' COVID-19 vaccination status had been checked. The manager agreed after the inspection to introduce a record.
“Staff told us they asked to see evidence of vaccination status for all visiting professionals, however, this was not recorded so we could not be assured the checks always took place.” from the report
- 01What has changed since the inspection to make sure essential carers and visiting professionals are tested or checked as required?
- 02How do you now screen visitors before they enter, and where is this recorded?
- 03How do you record cleaning of the visiting room and high-touch areas?
- 04What is your current process for safely admitting people from hospital, including any required isolation?
- 05What infection-control policies and guidance are now available to staff?
This was a targeted inspection of infection prevention and control, visiting arrangements and staffing pressures; the service was inspected but not rated overall. This explanation was written from the published report of 3 March 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 Oxendon House Care Home
5 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- February 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2022Inspected but not ratedSafe: Inspected but not rated
- January 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- May 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2014
Report published without a new overall rating.
- July 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 11 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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