CQC report explained · a nursing home
What the CQC found at Oxford Manor Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, November 2023
Alma Barn Lodge was rated Requires Improvement; inspectors found serious problems with risks, staffing, records and management oversight.
This was an unannounced focused inspection on 7 September 2023. Inspectors spoke with people, relatives and staff, observed care, and checked care records, medicines, recruitment files and management systems.
The home was not always safe. Risk records did not always show how known risks would be reduced. Records of repositioning, food and fluids, oral care and personal hygiene were incomplete. There were also concerns about staffing levels, cleanliness and staff training.
The home was rated Requires Improvement for Safe, Effective and Well-led. Caring and Responsive were not inspected during this visit, so their previous ratings were carried forward into the overall rating. The home remained in breach of several regulations after the previous inspection.
Kind staff
People said staff were kind, and some people said they would recommend the home because of this.
“People told us staff were kind.” from the report
Medicines
People received their medicines as prescribed and time-sensitive medicines were generally given on time. Staff had medicines training and their competence was checked.
“Medicines were managed safely. Records evidenced people received their medicines as prescribed.” from the report
Safe recruitment
The provider carried out relevant recruitment checks before staff started work.
“At this inspection we found the provider had recruited staff safely.” from the report
Healthcare access
People could access GPs, nurses and other health professionals when needed.
“Staff worked with external professionals to ensure people were supported to access health services and had their health care needs met.” from the report
Improved dementia environment
The provider had acted on a recommendation from the previous inspection and made improvements to the physical environment for people living with dementia.
“At this inspection we found the provider had acted on the recommendation and had made improvements.” from the report
Risk records
seriousRisk assessments and monitoring records were incomplete. This included repositioning, pressure damage, health conditions, food, fluids and checks to reduce known risks.
“People were at increased risk of skin pressure damage.” from the report
Staffing levels
seriousThere were not always enough staff on duty, and people sometimes waited for help. Inspectors found the provider had not supplied enough suitably trained staff.
“The provider had failed to ensure sufficient numbers of suitably trained staff were deployed.” from the report
Training and support
seriousSome staff had not received training in epilepsy, learning disability or managing distressed behaviour. Staff also reported a lack of supervision and management support.
“The provider had failed to ensure staff received appropriate training and support to enable them to carry out their duties.” from the report
Cleanliness
seriousSome bedrooms and furnishings were dirty, and stained bedsheets needed changing. The provider could not assure inspectors that the home was clean enough to prevent infection.
“The provider had failed to ensure the service was clean, and therefore, could not be assured of preventing the spread of infection.” from the report
Consent and capacity
seriousDecision-specific mental capacity assessments were missing, and the home did not always check that people giving consent had the legal authority to do so.
“The provider had failed to ensure care and treatment was provided with consent of the relevant person and to act in accordance with The Mental Capacity Act 2005.” from the report
Management oversight
seriousQuality systems did not identify or resolve important problems. Actions promised after the previous inspection, including auditing and supervision arrangements, were still incomplete.
“The provider had failed to ensure adequate systems and processes were in place to assess, monitor and improve the quality and safety of the care provided.” from the report
- 01What has changed to make sure there are enough suitably trained staff on every shift, including at night?
- 02How will you check and record repositioning, oral care, food, fluids and personal hygiene for my relative?
- 03What action has been taken to ensure all bedrooms, bedding and furnishings are kept clean?
- 04How are you completing decision-specific mental capacity assessments and checking who has legal authority to give consent?
- 05Who is currently responsible for managing the home, and how are you checking that the warning notice actions have been completed?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 4 November 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
Alma Barn Lodge was rated Requires Improvement; inspectors found kind care and safe medicines, but staffing, records and risk management were not reliable.
This was the first inspection since the service registered. Inspectors visited unannounced on 5 and 11 October 2022. They spoke with people, relatives, staff and health professionals, observed care, and checked care records, medicines, recruitment files, complaints and audits.
All five areas were rated Requires Improvement. Inspectors found people were not always protected from harm. Risk assessments and care records contained gaps or conflicting information. There were concerns about staffing levels, staff training, infection control, oral care, complaints and the way the home checked whether improvements had been made.
There were also positive findings. People said staff were kind and caring. Medicines were managed safely, people generally enjoyed their food, and people were supported to access health professionals. However, the overall rating means there was limited assurance that care was consistently safe, effective, person-centred and well managed.
Kind interactions
People and relatives generally described staff as kind and caring. Inspectors also saw positive, compassionate interactions during the visit.
“Throughout our inspection we observed positive interactions between people and staff.” from the report
Medicines
People received their medicines as prescribed. Storage, administration, recording and staff competency checks were found to be safe.
“People received their medicines as prescribed and the service had safe medicine storage systems in place.” from the report
Mealtimes
Inspectors saw that mealtimes were calm and people received support. Dietary and fluid needs were assessed and monitored.
“On the day of inspection we observed that mealtimes were not rushed and people were supported by enough members of staff.” from the report
Communication support
The home had identified communication needs and could provide information in different formats when requested.
“The provider complied with the Accessible Information Standard by identifying, recording, flagging, sharing and meeting the information and communication needs of people with a disability or sensory loss.” from the report
Risk records and safety
seriousRisk assessments contained conflicting or outdated information. Inspectors found gaps in repositioning records, incomplete injury records and weaknesses in learning from falls and other incidents.
“Systems were not robust enough to identify assess and manage the risks relating to the health safety and welfare of people.” from the report
Staffing and training
seriousStaffing levels varied and were sometimes low. Not all staff had the training or supervision needed to support people's needs safely.
“Sufficient numbers of suitably trained staff were not provided.” from the report
Personalised care
seriousCare plans did not consistently explain people's preferences, abilities or the support they needed. This meant care was not always tailored to the individual.
“Care plans lacked specific information on how people would like to be supported.” from the report
Quality checks
seriousAudits often recorded actions as completed without showing how problems had been fixed. Important shortfalls in records and daily care were not identified by the home's systems.
“The provider had failed to ensure there were effective governance and quality assurance measures in place.” from the report
Cleanliness and infection control
seriousInspectors were not always assured that the home was clean or that infection risks were properly controlled. They saw incorrectly worn masks and communal toilets without hand towels.
“We saw evidence that the service was not always clean, thus we were not reassured that the service assessed the risk of and prevented the spread of infection.” from the report
- 01What staffing levels are in place on each floor now, and how are they matched to residents' needs?
- 02Which staff have completed training in diabetes, seizures, dementia, oral care, infection control and safeguarding?
- 03How do you make sure risk assessments and care plans are accurate, consistent and updated after an incident or change in need?
- 04How are complaints recorded, investigated and followed up, and how are relatives told about the outcome?
- 05Who is currently responsible for managing the home while there is no registered manager?
This was an unannounced first full inspection covering all five CQC questions, including infection prevention and control; the service had no registered manager in post at the time. This explanation was written from the published report of 9 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 Oxford Manor Care Home
2 rated inspections over a year: the service has held its Requires improvement rating throughout.
- November 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- December 2022Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- May 2022
Registered with the Care Quality Commission on 13 May 2022.
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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Most charge £980 to £1,300 a week. 32 can care for a couple. 12 years' experience on average.
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