The Oaks Care Home

We carried out this assessment because we received concerns from the local authority, integrated care board (ICB) and local NHS infection control team about people’s care and support, the environment, infection control and the management of the home.

At our previous 2 inspections, the provider had been in breach of the legal regulations in relation to safe care and treatment and good governance. At this assessment, not enough action had been taken to improve and the provider remained in breach of these regulations. We also found an additional breach of the regulations relating to person-centred care.

There had been no registered manager in post since July 2024. An interim manager was in place at the time of our assessment. Staff, people and relatives spoke positively about them. A new manager had been recruited and was due to start following our assessment.

Risks relating to people’s care and support were not always effectively assessed, recorded, monitored and managed. Information regarding people’s nutrition and hydration, falls management, catheter care and positional changes to reduce the risk of pressure ulcers was not always accurate or detailed.

Records did not always evidence that an effective system was in place to ensure medicines were safely administered, stored and managed.

Action was being taken following the ICB, local authority and the local NHS infection control practitioners' visits in relation to the cleanliness of the home. When we visited, the home was cleaner, however, areas of wood and paint work were not intact which made it difficult to keep clean. Certain areas of the home, including several people’s bedrooms were malodourous. New non-slip flooring was going to be fitted in many of the carpeted rooms.

Prior to our assessment, training, supervision and appraisal meetings had not been carried out as planned. Training was being organised and carried out and a new supervision and appraisal planner had been implemented.

The home was in organisational safeguarding. This meant the local authority was monitoring the home and supporting them to ensure the correct procedures were in place to keep people safe. The provider put a voluntary suspension on admissions to the home to allow improvements to be made ensure people’s safety.

The provider had formulated an action plan prior to our assessment and updated it during and following our site visits and those visits carried out by the local authority and ICB, to ensure improvements were made.

A system to ensure regulatory requirements were met was still not in place. This was the third consecutive inspection the provider has been in breach of the regulations. There were shortfalls across the service in relation to medicines management, the environment, staff support and training, meeting people’s social needs, nutrition and hydration, the assessment of risk and record keeping.

We will request an action plan and meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good.