CQC report explained · a residential care home
What the CQC found at Twin Oaks
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were identified and managed, medicines were handled safely, staffing and recruitment were appropriate, and people were protected from abuse. Infection control arrangements were also considered suitable.
- Effective?
- Good
- This area was not inspected during this focused visit. Its rating was carried forward from the previous inspection.
- Caring?
- Good
- This area was not inspected during this focused visit. Its rating was carried forward from the previous inspection.
- Responsive?
- Good
- This area was not inspected during this focused visit. Its rating was carried forward from the previous inspection.
- Well-led?
- Good
- Inspectors found effective oversight and quality monitoring. Staff understood their roles, people and relatives were involved, and the manager worked with outside health professionals.
What inspectors found, July 2023
Twin Oaks was rated Good; inspectors found safe, well-managed care and improvements since the previous inspection.
This was an unannounced focused inspection on 15 June 2023. Two inspectors spoke with people, relatives and staff. They reviewed care records, medicines records, risk assessments, staff rotas, recruitment records and management systems. They also looked around the home.
The home was rated Good for Safe and Well-led. Inspectors found that risks, medicines, staffing, recruitment, safeguarding and infection control were managed appropriately. People said they felt safe and trusted the staff and management.
The previous inspection rated the home Requires Improvement and found breaches of regulations. At this inspection, improvements had been made and the home was no longer in breach. The earlier recommendation about medicines storage had also been acted on.
This was a focused inspection of Safe and Well-led only. The other areas were not inspected and their ratings were carried forward from the previous inspection.
Improved safety arrangements
Care records and risk assessments gave staff current guidance. Fire safety improvements had been put in place and checked by the fire service.
“Care records were up to date and included essential guidance for staff about keeping people safe.” from the report
Safe medicines practice
The home had improved its medicines storage and management since the previous inspection. Staff were trained and assessed as competent.
“Medicines were received, stored, administered and disposed of safely.” from the report
Suitable staffing and recruitment
Inspectors found enough staff and the required recruitment checks had been completed. People said they did not have to wait for support.
“Records showed that necessary checks were made to ensure staff were suitable for the role.” from the report
Positive relationships
People and relatives described the management as approachable and said they were involved in care reviews and changes to care plans.
“People were positive about the quality of service they received.” from the report
Clean and infection-aware home
Inspectors were assured that the home had suitable infection prevention arrangements and that visits were being supported without restrictions.
“The home was clean, tidy and well maintained.” from the report
No formal lessons-learned system
minorThe provider did not have a formal system to make sure lessons were learnt from incidents. Inspectors saw evidence that outcomes were shared with staff, but the lack of a formal process is worth asking about.
“The provider had no formal system to ensure lessons were learnt from incidents.” from the report
- 01How do you now make sure lessons are formally recorded and acted on after incidents?
- 02How are the fire safety improvements checked and kept up to date?
- 03How are medicines stored and audited since the changes made after the previous inspection?
- 04How will you monitor the areas that were not covered by this focused inspection?
- 05How are relatives involved when care plans or support need to change?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous inspection. This explanation was written from the published report of 21 July 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, February 2022
Requires Improvement; inspectors found risks in care records, safety checks, recruitment and management oversight.
This was an unannounced focused inspection on 20 and 21 January 2022. Inspectors looked only at Safe and Well-led, after concerns about an incident and management oversight. They spoke with people, relatives and staff, checked care, medicine and recruitment records, and looked around the home.
The home was rated Requires Improvement for Safe and Well-led. Care plans and risk assessments were incomplete or out of date. Fire safety checks, evacuation plans and some equipment checks were not always in place. Recruitment checks did not always show that staff were suitable to work with vulnerable people.
Management oversight was not effective. Some care records had been completed before care was given, which could make them misleading. Inspectors found no evidence that people had been harmed, but said these issues increased the risk of harm. The provider began extra checks and monitoring during and after the inspection.
The overall rating fell from Good at the previous inspection in 2018 to Requires Improvement. The other three key questions were not inspected, so their previous ratings were used in the overall rating.
Safeguarding
Staff understood how to recognise and report abuse. Inspectors found the safeguarding processes robust.
“The service's safeguarding processes were robust.” from the report
Infection control
Inspectors were assured that the home had suitable infection prevention arrangements, including hygiene, protective equipment and visiting arrangements.
“The home was clean, tidy and well maintained.” from the report
Medicines given correctly
People received their medicines as prescribed. Staff had training in safe administration, although storage needed improvement.
“People received their medicines when they should.” from the report
Access to professionals
The home worked with outside health and care professionals and made referrals when people needed additional support.
“The management and staff team had established good working relationships with a variety of professionals within the local community.” from the report
Incomplete risk information
seriousSome care plans and risk assessments were missing important information. Inspectors found nutritional risks that had not been properly assessed or followed up.
“Care records were not always up to date and did not include essential guidance for staff around keeping people safe.” from the report
Fire and equipment checks
seriousSome people did not have emergency evacuation plans. Fire safety processes and some checks on equipment were not completed or recorded.
“Some people did not have Personal Emergency Evacuation Plans in place (PEEP's).” from the report
Recruitment checks
seriousSome essential employment checks were missing. In one case, the service had not properly reconsidered a staff member's suitability after circumstances changed.
“Records showed some necessary checks were not made to ensure staff were suitable for the role.” from the report
Management oversight
seriousThe provider's monitoring systems did not identify several problems. Some daily records were completed before care was provided, which could give a false impression.
“The provider's systems and processes for the oversight and quality monitoring of the service had not been effective in addressing concerns we found during the inspection.” from the report
Medicine storage
needs fixingSome medicines were stored in unsuitable places, including a fridge without a thermometer. The provider was asked to improve storage in line with guidance.
“Sometimes medicines were not always stored safely.” from the report
- 01Have all care plans and risk assessments, including nutritional risks, now been updated and reviewed?
- 02Do every resident's Personal Emergency Evacuation Plan and the home's fire safety checks now exist and have documented reviews?
- 03What changes have been made to recruitment checks, including checks when a staff member's circumstances change?
- 04How do managers now check that daily care records are completed after care is provided and accurately describe what happened?
- 05How are medicines stored and checked against the manufacturer's instructions?
This was a focused inspection of Safe and Well-led only; the other three key question ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 23 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.
Every inspection of Twin Oaks
6 rated inspections over 8 years: the service has improved, from Inadequate to Good.
- July 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2022Requires improvementSafe: Requires improvementWell-led: Requires improvement
- June 2021Inspected but not ratedSafe: Inspected but not rated
- May 2018Goodstayed GoodSafe: GoodWell-led: Good
- March 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- June 2015InadequateSafe: InadequateEffective: InadequateCaring: GoodResponsive: InadequateWell-led: Inadequate
- February 2014
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 9 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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