Archived: Oaks Court House

Updated 27 January 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by two inspectors and an expert by experience. The expert by experience was used to make telephone call to relatives. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Oaks court house is a 'care home'. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since our last inspection, including notifications the provider had sent to us. We also gathered feedback from the local authority and other health professionals who had attended the home.

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We took this into account when we inspected the service and made the judgements in his report. We used all of this information to plan our inspection.

During the inspection

We spoke with 4 people living in the home, 8 relatives and 1 friend. We looked at the care records for 17 people. We spoke with the nominated individual, registered manager and deputy manager. We spoke with 6 care staff and a member of the kitchen staff. We checked that the care people received matched the information in their records. We also observed the care people received in communal areas. We looked at records relating to the management of the service, including audits carried out within the home.

Updated 27 January 2023

About the service

Oaks court house is a care home providing personal care to for up to 41 older people. People have access to their own bedroom along with communal spaces including lounges and gardens. At the time of our inspection there were 35 people at the home, some who are living with dementia.

People’s experience of using this service and what we found

When incident’s and accidents had occurred, action had not been taken to reduce the risk of reoccurrence, placing people at risk of significant harm as these incidents continued to occur. Risks to people were not managed in a safe way and action was not taken to ensure people’s safety. Safeguarding incidents had not been appropriately reported or investigated placing people at risk of harm. People did not receive their medicines as prescribed and there was a lack of guidance in place for ‘as required’ medicines meaning people may not have these when needed. There were no evidence lessons were being learnt when things went wrong.

People were not supported to have maximum choice and control of their lives and staff did not 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.

There were concerns with the environment, the kitchen was unhygienic and other areas of the home were in need of repair. There were concerns with the risk of cross infection as staff were not always wearing masks correctly.

People did not always have access to health professionals and when advice had been sought this had not always been followed. There were not enough suitably trained staff to support people. Staff had not always received up to date training or some had not received training at all.

People were not involved with their care or were not always able to make choices throughout their day. There was no evidence to show how they were involved with this. Care plans and risk assessments were not always in place and staff did not have information to support people in a safe way. People’s preferences were not always considered. People were not treated in a dignified way.

The systems in place had failed to identify concerns or areas of improvement. The lack of oversight in the home placed people at risk of harm.

We saw some nice interactions between people and staff. There was a complaints procedure in place that was followed when needed.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (4 September 2021)

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.

Why we inspected

The inspection was prompted in part due to concerns received about the care people received. A decision was made for us to inspect and examine those risks.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from requires improvement to inadequate based on the findings of this inspection.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Oaks court house on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment of people including medicines management, staffing levels and staff training, the home’s environment, the lack of dignity provided to people, how people are safeguarded, how people are involved with their care and how the home is governed at this inspection.

We issued a Notice of Proposal to vary a condition on the providers registration and remove the location Oaks Court House.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.