Oak Cottage

We found 6 breaches of regulations relating to person-centred care, staffing, consent, safeguarding, premises and good governance. ​3 of these breaches relating to person centred care, staffing and good governance were continued from our previous assessment on 24 November 2024.

We identified widespread concerns at this assessment, which had not been identified and mitigated by the provider through their own governance systems.

People were not active partners in their care. Although staff knew people well, their care records did not reflect this knowledge. Risks to people were not identified, reviewed when needed or have sufficient assessment plans in place to ensure those risks were mitigated.

Staff and management were not provided with the necessary training to support them in their specific roles. Care staff had limited training to support people’s specialist needs, such as dementia. Managers had little training to support effective supervision, appraisal of staff and to effectively manage the service. No staff member had fully completed their training modules over the past 12 months.

Legal requirements relating to capacity and consent were not consistently in place, and systems for safeguarding were ineffective, placing people at risk of harm.

The provider’s oversight and governance of the service had been ineffective in identifying and addressing failings in safety, quality, and standards, as detailed in the Safe, Effective, and Well-Led sections of this report. This contributed to both continued breaches of regulations alongside newly imposed breaches of legal regulation. The provider and / or registered manager did not have clear responsibilities, roles, systems of accountability or good governance. The service lacked a clear vision of the direction and standards they wished to see at the home and had not implemented effective and robust quality assurance systems that led to the delivery of demonstrable improvements.

This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide. In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward. We have also asked the provider for an action plan in response to some of the concerns found at this assessment.