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Tall Oaks Care Home Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 5 August 2021

About the service

Tall Oaks Care Home is a residential care home providing personal and nursing care for 43 people at the time of the inspection. Tall Oaks Care Home can accommodate up to 55 people aged 65 and over across two floors.

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

People’s risks were not always managed safely. Plans in place for people who required support with their nutritional needs were not always monitored, which put people at risk of malnutrition and dehydration.

Lessons were not always learnt, and quality assurance systems were not always effective in identifying the shortfalls in people’s care records. Although people had been referred to other professionals, these were not followed up, which prolonged ineffective care for people.

The majority of 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.

Not all staff had undergone the necessary training, which put people at risk. There were sufficient numbers of staff to meet people’s needs.

The management of medicines had improved since last inspection. However, people had access to fluid thickening powders which could cause harm if ingested.

Infection and prevention control practices were in place and in large were effective in reducing the risk of the spread of infection.

Relatives told us they felt their loved ones were safe and were kept informed of their changing needs by staff who had been safely recruited.

There was a positive culture in the home and staff felt they were supported.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 25 November 2019) and there was a breach of regulation. The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection although we found improvements had had been made in relation to the management of medicines, the provider remained in breach of regulations.

Why we inspected

We received concerns in relation to people not receiving adequate care and support. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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 not changed from requires improvement. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvements. Please see the safe, effective and well led sections of this full report.

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 Tall Oaks Care Home on our website at


We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement

Inspection areas


Requires improvement

Updated 5 August 2021

The service was not always safe.

Details are in our safe findings below.


Requires improvement

Updated 5 August 2021

The service was not always effective.

Details are in our effective findings below.



Updated 5 August 2021



Updated 5 August 2021


Requires improvement

Updated 5 August 2021

The service was not always well-led.

Details are in our well-led findings below.