8 November 2023
During an inspection looking at part of the service
People's experience of the service and what we found:
People were not always protected from the risk of abuse. Incidents were identified and reported, but not investigated or reported to the local authority. There was not always evidence of learning following incidents. However, people told us they felt safe.
People said staff were not always deployed appropriately to support them when needed. Medicines management required improving to ensure people received their medicines. Risks were not always fully assessed and documented. Improvements were needed to some infection controls practices and maintenance of the property in the service.
People's health needs were not always fully planned for, so staff did not always have detailed guidance. Staff told us they received training, however we found key gaps in their training records. Some areas of the service needed refurbishing to meet the needs of people living there.
Feedback about the food provided to people was mixed. The chef did not have the required training to support people’s specific dietary needs. Weights had not been monitored as required, and fresh fruit and snacks were not always available.
People were not supported to have maximum choice and control of their lives. Staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. Although we did see staff asking people consent before supporting them.
Quality assurance systems in place were not effective at monitoring the quality and safety of people's care. Notifications were not always submitted as required. People did not feel the management team were visible or responsive to them.
People were able to access healthcare professionals as needed and staff knew people’s support needs well. Staff were seen to be caring and attentive in their approach and had formed positive, friendly relationships with people. Staff felt they worked well as a team and felt supported by the management team. The registered manager was open to feedback and eager to make improvements through the inspection.
Rating at last inspection and update
The last rating for this service was requires improvement [published 11 April 2019] and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.
The last rating for this service was requires improvement (published 11 April 2019). This service has been rated requires improvement on 4 out of 5 previous inspections since 04 February 2015.
Why we inspected
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions safe, effective and well-led which contained those requirements.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Oak Cottage on our website at www.cqc.org.uk.
Enforcement and Recommendations
We have identified breaches in relation to staffing, consent, safe care and treatment, staff support and governance arrangements at this inspection.
Follow Up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.