CQC report explained · a residential care home
What the CQC found at Three Oaks Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, March 2019
Three Oaks Residential Care Home was rated Good overall; care was safe, kind and responsive, but management checks and some records needed improvement.
The inspection took place on 3 February 2019 without advance notice. One inspector spoke with six people, two relatives, staff, managers, visitors and a health professional. The inspector also reviewed care records, medicines records, policies and recruitment files.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found people were protected from harm, received medicines safely, had enough staff and were supported by staff who knew their needs and preferences.
Well-led was rated Requires Improvement. Some care records were incomplete or not sufficiently focused on the individual, and the home's checks did not always identify areas needing improvement. The provider said records relating to the Mental Capacity Act and care plans were being reviewed after the inspection.
The overall rating remained Good. However, this was a lower rating for management than at the previous inspection in December 2016, when all areas were rated Good.
Safe care and medicines
Inspectors found that people were protected from avoidable harm and that medicines were administered, stored and recorded safely.
“Medicine administration was safe and medicines were stored appropriately.” from the report
Kind and respectful staff
Staff treated people with compassion and respect. They knew people well, listened to them and supported their dignity and independence.
“Our observations of staff interactions with people showed that people were treated with kindness, compassion, dignity and respect.” from the report
Personalised support
Care plans included people's preferences and routines, and staff understood their interests and support needs.
“Care plans contained information about people's needs. For example, information relating to personal preferences, routines and how a person preferred to spend their time.” from the report
Enough trained staff
The home had sufficient staffing and staff had completed induction training and relevant checks before starting work.
“Sufficient staffing numbers were deployed to ensure people's needs were met.” from the report
Management checks
needs fixingGovernance systems did not always identify problems or drive improvement. Some care records were incomplete and were not consistently person-centred.
“Governance systems were not always effective in recognising and driving improvement.” from the report
Accessible information
needs fixingStaff knew about the Accessible Information Standard, but inspectors were told that more work was needed. The manager said the guidance would be reviewed and improvements made.
“Staff were aware of the AIS but told us more work could be done to make improvements.” from the report
- 01Have all care plans and Mental Capacity Act records now been reviewed and updated?
- 02How do managers check that care records are complete, accurate and centred on each person?
- 03What changes have been made following the Requires Improvement rating for well-led?
- 04How will you make sure information is accessible for people with communication needs, disabilities or sensory loss?
- 05How are relatives involved in care reviews and decisions about activities and daily routines?
This was a planned inspection covering all five CQC questions; the inspector reviewed three care records and medicines records, and the report says no Provider Information Return was requested. This explanation was written from the published report of 22 March 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, December 2016
Rated Good; inspectors found safe, kind and responsive care at Three Oaks Residential Care Home.
This was an unannounced inspection on 1 November 2016. One inspector observed care, checked records and medicines, and spoke with people, relatives, staff, managers and a visiting GP.
The home supported 19 older people in a 20-bed care home without nursing. Inspectors found enough staff, suitable recruitment checks, safe medicines management and appropriate risk assessments. Staff training was up to date.
People were treated with kindness and respect. Care plans reflected people's preferences, food and drink were available, healthcare needs were followed up, and activities and outings were offered.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. This means the inspection found the service meeting the required standards at that time.
Safety and staffing
Inspectors found enough staff to meet people's needs and suitable recruitment checks. Staff understood how to recognise and report possible abuse.
“There were sufficient numbers of staff to support people and safe recruitment practices were followed.” from the report
Kind care
People and relatives spoke positively about staff. Inspectors saw warm, patient and respectful interactions.
“Positive, caring relationships existed between people and the staff who looked after them.” from the report
Personalised support
Care plans recorded people's likes, dislikes, routines and the support they needed. People were involved in their care and reviews.
“Care plans were person centred and explained what the person could do for themselves and what support was needed from staff.” from the report
Activities and choice
People could choose from activities such as quizzes, arts and crafts, music, singing, dancing and trips out. They could also choose not to join in.
“There were a variety of activities and outings on offer which people could choose to do.” from the report
Quality checks
The home used regular audits and outside checks to monitor the quality and safety of its service. Action plans were made when issues were found.
“Regular audits took place to measure the quality and safety of the service provided.” from the report
Inspectors raised no specific concerns in this report.
- 01How many staff are on duty now on each shift, and how would staffing change if people's needs increased?
- 02How are new residents' needs assessed before they move in, particularly if they have dementia or need more support?
- 03How often would my relative's care plan be reviewed, and how would they and their family be involved?
- 04What activities and outings are currently available, and how do you find out what each person enjoys?
- 05How would I raise a concern or complaint, and how would you keep me informed about the response?
This was an unannounced inspection of the overall service and all five CQC questions; the previous inspection in January 2014 found no concerns. This explanation was written from the published report of 6 December 2016 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 Residential Care Home
2 rated inspections over 2 years: the service has held its Good rating throughout.
- March 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Three Oaks Residential Care Home →
- December 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Three Oaks Residential Care Home →
- February 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 25 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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