CQC report explained · a residential care home
What the CQC found at Three Oaks Care Home Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, appropriate recruitment checks, safe medicines administration and risk assessments. Staff understood how to recognise and report abuse.
- Effective?
- Good
- People had assessments and care plans based on their health needs and choices. Staff supported access to healthcare, nutrition, training and least restrictive decision-making.
- Caring?
- Good
- Staff were observed to be kind, respectful and reassuring. People were supported to make choices, maintain privacy and remain as independent as possible.
- Responsive?
- Good
- Care plans recorded people's communication methods, preferences and interests. People were supported with activities, outings, relationships and raising complaints.
- Well-led?
- Requires improvement
- The ratings table gave this area Requires Improvement because the manager was not registered with the CQC at the time. The report also found regular audits, supportive leadership and action taken after incidents.
What inspectors found, November 2019
Three Oaks Care Home Limited was rated Good overall, but well-led was rated Requires Improvement because the manager was not registered at the time.
This was an unannounced inspection on 14 October 2019, with further information received on 15 October. The inspector spoke with people, relatives, staff, the acting manager and commissioners. They also reviewed care files, staff records, training records and other service documents.
The home was rated Good for safe, effective, caring and responsive care. Inspectors found enough staff, safe medicines systems, personalised care plans, kind staff and support for people's choices, communication, activities and healthcare.
The overall rating was Good. However, the ratings table gave well-led a Requires Improvement rating. The report noted that the manager was not registered with the CQC at the time, although the provider said they were going through the registration process. The detailed well-led section otherwise described the service as well managed, with regular audits and learning from incidents.
Kind and respectful staff
Inspectors saw staff treating people with patience, kindness and respect. Relatives also said staff were caring and kept them informed.
“During our visit we observed staff were always courteous and kind towards people they supported.” from the report
Personalised support
Care plans included people's likes, dislikes, communication methods and interests. Staff used this information to provide individual support.
“People's care plans were detailed with regards to people's likes, dislikes and preferences.” from the report
Safe staffing and medicines
Inspectors found enough staff to meet people's needs and found no gaps in the medicines administration records.
“There were enough staff to meet people's needs safely.” from the report
Choice and independence
People were supported to make choices, take positive risks and be involved in decisions about their care.
“People were included in their care, their opinion mattered, and they were supported to live life being active part of their community.” from the report
Larger than current best practice guidance
minorThe home was registered for up to 13 people and ten people were living there. Inspectors said its size was larger than current best practice guidance, although they found the building design helped reduce any negative impact.
“This is larger than current best practice guidance.” from the report
- 01Is the manager now registered with the CQC, and who is responsible for the home if registration is still pending?
- 02How do you check that care plans and risk assessments remain accurate when people's needs change?
- 03How will my relative's preferred communication methods be recorded and used by staff?
- 04What activities and outings would be available to my relative based on their interests?
- 05How are families involved in reviews, complaints and decisions made in their relative's best interests?
This was an unannounced comprehensive inspection covering all five key questions; the previous overall rating was Good and was published in April 2017. This explanation was written from the published report of 7 November 2019 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, April 2017
Three Oaks Care Home Limited was rated Good; inspectors found safe, kind and personalised care, with a few records and improvement actions still being fine-tuned.
This was an unannounced inspection on 21 March 2017. One inspector observed care, spoke with staff, managers and relatives, received feedback from health and social care professionals, and reviewed care, medicines, staff and quality records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were safe, supported by enough trained staff, given appropriate food and healthcare, and treated with kindness, dignity and respect.
The home had improved since the previous inspection in May 2016, when it breached Regulation 17 about record keeping and management. Most of the required improvements had been made, although some outdated care plan information and minor monitoring issues remained.
Safe support
Risks were assessed in detail and reviewed as people's needs changed. Staff knew how to respond to abuse concerns and used appropriate moving and handling techniques.
“Potential risks to people's health, well-being or safety had been identified, assessed and reviewed regularly to take account of people's changing needs and circumstances.” from the report
Kind and respectful staff
Staff knew people well and supported their choices, dignity and independence. Inspectors saw warm relationships and calm, considerate care.
“Staff respected people's dignity and made sure that they supported people in the way they wished whilst encouraging them to remain as independent as possible.” from the report
Activities and independence
People were supported with activities in the home and community, including holidays and day trips. Some people also took part in household tasks to build independence and self-esteem.
“There were a variety of activities, both in house and in the community for people to engage with.” from the report
Improved leadership
The home had made most of the improvements required after the previous inspection. Records, handovers, recruitment information and care plans had generally been strengthened.
“At this inspection we found that the provider had made the majority of the required improvements with some minor 'fine tuning' still in progress.” from the report
Medicine stock records
needs fixingAll checked medicines had been signed for when given, but carry-forward amounts were not always recorded on the current medicine administration record. The manager agreed to make this routine.
“We checked a random sample of nine boxed medicines against the medicine administration records (MAR).” from the report
Outdated care plan information
needs fixingSome care plans still contained outdated information. The manager said it would be removed to reduce the risk of confusion for newer staff.
“There was some out dated information within care plans we viewed that the registered manager undertook to remove to help avoid any confusion when new staff members accessed them.” from the report
Tracking improvement actions
needs fixingActions from meetings and satisfaction surveys were not always brought into the main service improvement plan. This meant they were not continually monitored for timely completion.
“Action plans were developed as a result of these meetings however, these did not feed into the overall service improvement plan so were not continually monitored to check that action had been taken in a timely manner.” from the report
- 01How do you now record carry-forward medicine amounts on the current medicine administration records?
- 02How often are care plans checked for outdated information, and who makes sure changes are followed by all staff?
- 03How are actions from relatives' meetings and satisfaction surveys now recorded and tracked to completion?
- 04What arrangements are in place to manage the staff vacancies the manager expected in the near future?
- 05How will you show us that the improvements made since the May 2016 inspection are being maintained?
This was an unannounced comprehensive inspection covering all five key questions and the overall quality of the home. This explanation was written from the published report of 13 April 2017 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 Three Oaks Care Home Limited
6 rated inspections over 5 years: the service has improved, from Inadequate to Good.
- November 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Three Oaks Care Home Limited →
- April 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Three Oaks Care Home Limited →
- June 2016Requires improvementstayed Requires improvementSafe: GoodEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- February 2016Requires improvementstayed Requires improvementWell-led: Requires improvement
- September 2015Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2015InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- September 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 18 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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