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Tall Oaks Care Home Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 26 November 2019

About the service

Tall Oaks Care Home is a residential care home that provides personal and nursing care for up to 55 people. Four of the 55 beds were allocated and funded by the local Clinical Commissioning Group to assess and plan for people to return home after a hospital admission. The accommodation is provided in a single building, arranged over two floors, with communal facilities including dining rooms and lounges on both floors. At the time of our inspection 43 people were using the service, some of whom were living with dementia.

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

People were at risk of not always receiving a safe service because medicines were not always managed safely and monitoring records were not consistently completed and reviewed to assure us that appropriate action was always taken. The provider had quality assurance systems to drive improvement, but these had not identified the shortfalls we found in these areas.

People felt safe and were protected from the risk of harm by staff who understood their responsibilities to identify and report any signs of potential abuse. There was a consistent approach to safeguarding and any concerns were taken seriously and referred to the local safeguarding authority for investigation.

There were sufficient, safely recruited staff to keep people safe and promote their wellbeing. Staff received training and ongoing support to meet people’s individual needs. People had choice over their meals and were supported to access other professionals to maintain good health.

Staff had good relationships with people and always promoted their privacy, dignity and independence. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People received personalised care from staff that knew them well. People’s diversity was recognised and promoted by the staff and systems were in place to meet people’s communication needs. People had opportunities to take part in activities and social events and were supported to follow their hobbies and spiritual beliefs. Staff were proactive and ensured people received timely and dignified care at the end of their life.

People and their relatives had no complaints and felt confident raising any concerns with the staff and acting manager. There were systems in place to capture people’s views on how the service could be improved and these were acted on. Staff felt supported and valued by the acting manager and management team.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was Good (published 29 April 2017). At this inspection we found evidence that the provider needs to make improvements with the management of medicines and governance of the service and the overall rating has declined to Requires Improvement.

Why we inspected

This was a planned inspection based on the previous rating.


We have identified a breach in relation to the management of medicines. Please see the action we have told the provider to take at the end of this report.

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 continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection areas


Requires improvement

Updated 26 November 2019

The service was not always safe.

Details are in our safe findings below.



Updated 26 November 2019

The service was effective.

Details are in our effective findings below.



Updated 26 November 2019

The service was caring.

Details are in our caring findings below.



Updated 26 November 2019

The service was responsive.

Details are in our responsive findings below.


Requires improvement

Updated 26 November 2019

The service was not always well-led.

Details are in our well-led findings below.