CQC report explained · a residential care home
What the CQC found at Red Oak Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some window restrictors did not meet safety guidance and exposed people to a risk of falls from height. Inspectors found that suitable restrictors had been fitted by the third day.
- Effective?
- Good
- This key question was not inspected during this focused visit. The rating from the previous comprehensive inspection was used in calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. The rating from the previous comprehensive inspection was used in calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. The rating from the previous comprehensive inspection was used in calculating the overall rating.
- Well-led?
- Requires improvement
- The audit system had not identified that window restrictors failed to meet guidance. Inspectors also found conflicting information from staff about staffing arrangements.
What inspectors found, February 2022
Red Oak Care Home is rated Requires Improvement; inspectors found window safety and quality checks needed improvement, although care and medicines support were generally safe.
Inspectors visited on 5, 6 and 13 January 2022. They spoke with people, relatives, staff and managers. They checked medicines, care records, recruitment files, infection control and how the home was managed.
The home was not always safe. Window restrictors in private and communal rooms did not meet safety guidance and could allow windows to open too far. This created a risk of falls from height. Suitable restrictors were fitted by the third day of the inspection.
People said they felt safe and staff helped them when needed. Medicines were managed safely, staff understood people's risks and infection control arrangements were satisfactory. However, staff gave different information about staffing, and audits had not identified the window safety problem.
The overall rating changed from Good to Requires Improvement. This was a focused inspection of Safe and Well-led only. Ratings from the earlier comprehensive inspection were used for the other areas.
People felt safe
People told inspectors they felt safe, trusted staff and received help when they asked for it.
“People told us they felt safe and they trusted staff.” from the report
Medicines support
Medicines were stored and administered safely. Staff had training and their competence was checked.
“The provider ensured staff received training and their competency to administer medicines was assessed.” from the report
Risk support
Staff understood the support people needed. Equipment introduced for one person had helped reduce their falls.
“A relative shared the number of falls a loved one had experienced had decreased "dramatically.” from the report
Infection control
Inspectors were assured that the home had suitable infection prevention arrangements, including cleaning, protective equipment and visiting arrangements.
“We were assured that the provider was using PPE effectively and safely.” from the report
Unsafe window restrictors
seriousRestrictors on windows in 13 private rooms and three communal rooms did not meet safety guidance. Windows could be opened more than 100mm, creating a risk of falls from height.
“This placed people at risk from avoidable harm from falls at height as restrictors were not tamperproof and windows could be opened to more than 100mm.” from the report
Audits missed a safety problem
seriousThe home's checks did not identify that the window restrictors were unsuitable. Inspectors said the audit system did not consistently drive improvement.
“The audit system had not identified the window restrictors did not meet HSE guidance.” from the report
Unclear staffing arrangements
needs fixingThe manager said staffing was sufficient, but some staff said more staff were needed at weekends. Inspectors recommended that the provider use best-practice information to calculate staffing.
“Some staff who worked at the home told us that they were happy with the staffing arrangements, others told us more staff were required at weekends.” from the report
- 01Have all window restrictors now been checked and confirmed to meet the relevant safety guidance?
- 02How will you make sure your audits identify equipment and safety problems before someone could be harmed?
- 03How many staff are planned for each shift, particularly at weekends, and how is this number calculated?
- 04What actions were included in the improvement plan after the two breaches, and which actions remain outstanding?
- 05How will you show families that the improvements are being maintained before CQC returns?
This was a focused inspection of Safe and Well-led only; the other key question ratings from the previous comprehensive inspection were carried forward into the overall rating. This explanation was written from the published report of 10 February 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.
What inspectors found, February 2021
Rated Good; inspectors found safe infection control, medicines and staffing, with strong management systems.
This was an announced inspection on 21 January 2021. One inspector reviewed information about the home, spoke with one resident, a relative and two staff members, and talked with the managers. The inspector also walked around the building.
The inspection focused on whether people were safe and whether the home was well led, including its response to the coronavirus pandemic. Inspectors found suitable infection control arrangements, enough protective equipment, safe medicines processes, reviewed risk assessments and appropriate staffing.
Inspectors found that managers used audits, reviewed incidents and shared lessons with staff. People and staff spoke positively about the care and management. Both Safe and Well-led were rated Good.
The other three areas, Effective, Caring and Responsive, were not inspected at this visit. Their previous ratings from the last comprehensive inspection were used in the overall rating.
Infection control
The home had enhanced infection control procedures during the pandemic. Inspectors saw staff using PPE correctly and found enough supplies.
“We checked personal protective equipment (PPE) and found sufficient stocks available and staff confirmed they were not short of equipment.” from the report
Safe care
Risk assessments were thorough and regularly reviewed. Staff had training and showed awareness of protecting people from abuse.
“Care records for people confirmed thorough risk assessments were in place and regularly reviewed if changes occurred.” from the report
Medicines and staffing
Inspectors found systems for safe medicines administration and checks. Staffing arrangements were designed to meet people's assessed needs.
“The management team had good systems and procedures to manage people's medication safely.” from the report
Management and teamwork
The home used audits, learned from incidents and encouraged people's views. Staff described the management team as supportive and fair.
“The management team had good auditing systems to maintain ongoing monitoring of Red Oak.” from the report
Inspectors raised no specific concerns in this report.
- 01How are the infection control procedures and PPE supplies being kept up to date now?
- 02How often are each person's risk assessments reviewed, and what happens when their needs change?
- 03How are medicines checked, and how are any discrepancies followed up?
- 04What did the most recent surveys say about people's experience, and what changes were made as a result?
- 05When were Effective, Caring and Responsive last fully assessed, and what were their ratings?
This was a focused inspection of Safe and Well-led, including infection prevention and control; Effective, Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 13 February 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 Red Oak Care Home
6 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- February 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2021Goodstayed GoodSafe: GoodWell-led: Good
- February 2020Goodup from Requires improvementSafe: GoodWell-led: Good
- February 2019Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 6 December 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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