All inspections: Oak Cottage - Care Quality Commission

Date of Assessment: 13 November 2025 to 09 December 2025. The service is a residential care home providing support to up to 25 people, including those living with dementia and mental health support needs. At the time of this assessment twenty people were receiving personal care.

We found 6 breaches of regulations relating to person-centred care, staffing, consent, safeguarding, premises and good governance. 3 of these breaches relating to person centred care, staffing and good governance were continued from our previous assessment on 24 November 2024.

We identified widespread concerns at this assessment, which had not been identified and mitigated by the provider through their own governance systems.

People were not active partners in their care. Although staff knew people well, their care records did not reflect this knowledge. Risks to people were not identified, reviewed when needed or have sufficient assessment plans in place to ensure those risks were mitigated.

Staff and management were not provided with the necessary training to support them in their specific roles. Care staff had limited training to support people’s specialist needs, such as dementia. Managers had little training to support effective supervision, appraisal of staff and to effectively manage the service. No staff member had fully completed their training modules over the past 12 months.

Legal requirements relating to capacity and consent were not consistently in place, and systems for safeguarding were ineffective, placing people at risk of harm.

The provider’s oversight and governance of the service had been ineffective in identifying and addressing failings in safety, quality, and standards, as detailed in the Safe, Effective, and Well-Led sections of this report. This contributed to both continued breaches of regulations alongside newly imposed breaches of legal regulation. The provider and / or registered manager did not have clear responsibilities, roles, systems of accountability or good governance. The service lacked a clear vision of the direction and standards they wished to see at the home and had not implemented effective and robust quality assurance systems that led to the delivery of demonstrable improvements.

This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide. In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward. We have also asked the provider for an action plan in response to some of the concerns found at this assessment.

Oak Cottage is a residential care home providing accommodation for up to 25 people who require personal care. The service provides support to older people living with dementia and mental health support needs. At the time of our inspection there were 17 people using the service of which 10 people received personal care.

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.

About the service: Oak Cottage is registered to provide accommodation and personal care for up to 21 people. At the time of inspection, 20 people were using the service.

People’s experience of using this service:

• People were not always protected from the risk of harm, because appropriate window restrictors were not in place on the first floor of the building, to ensure people’s safety.

• Staff had not always received the required training. Many staff had received an induction to the service, but no formal training had taken place.

• Audits were not always effective. There were no effective audits on staff training. Training records kept were out of date, and there was no oversight on staff training.

• This was the second time we had found a lack of training within the service. At a previous inspection in July 2014, staff were not sufficiently trained.

• Timely action was not always taken to respond to known areas of required improvement.

• People told us they felt safe. Staff understood safeguarding procedures.

• Risk assessments were in place to manage risks within people’s lives.

• Staff recruitment procedures ensured that appropriate pre-employment checks were carried out.

• Staffing support matched the level of assessed needs within the service during our inspection.

• Staff were supervised well and felt confident in their roles.

• People were supported to have a varied diet.

• Healthcare needs were met, and people had access to health professionals as required.

• People's consent was gained before any care was provided, and they were supported to have maximum choice and control of their lives.

• Staff treated people with kindness, dignity and respect and spent time getting to know them.

• People were supported in the least restrictive way possible.

• Care plans reflected people’s likes, dislikes and preferences.

• People were able to take part in a wide range of activities and outings.

• People and their family were involved in their own care planning as much as was possible.

• A complaints system was in place and was used effectively.

• The registered manager worked in partnership with outside agencies to improve people’s support when required

• The service had a registered manager in place, and staff felt well supported by them.

Rating at last inspection: Good (report published 23/08/2016)

Why we inspected:

• This was a planned inspection based on the rating at the last inspection.

Enforcement

• Please see ‘the action we have told the provider to take’ section towards the end of the report.

Follow up:

• We will continue to monitor the service through the information we receive until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

We carried out an unannounced inspection on 12 July 2016.

Oak Cottage provides care and support for up to 21 older people. At the time of the inspection, there were 18 people being supported by the service.

The service has a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

There were risk assessments in place that gave guidance to staff on how risks to people could be minimised and how to safeguard people from the risk of possible harm.

The provider had effective recruitment processes in place and there were sufficient staff to support people safely. Staff understood their roles and responsibilities and would seek people’s consent before they provided any care or support. Staff received supervision and support, and had been trained to meet people’s individual needs.

People were supported by caring and respectful staff who they felt knew them well. Relatives we spoke with described the staff as kind and caring. People were supported to be part of the community and visit the local area.

People had been assessed, and care plans took account of their individual needs, preferences, and choices. Staff supported people to be as independent as possible.

The provider had a formal process for handling complaints and concerns. They encouraged feedback from people and acted on the comments received to continually improve the quality of the service. The provider also had effective quality monitoring processes in place to ensure that they were meeting the required standards of care.

We carried out an unannounced inspection on 5 November 2015. The service had been last inspected in January 2015 in response to concerns about the quality of the service provided. We had looked at whether the service was safe, effective and caring and we found they had not met five regulations. This was because we had concerns about how people’s medicines were managed and the environment was not always safe. Also, care had not always been provided in a way that achieved good results for people who used the service. We told the provider to make the required improvements and they told us what action they would take to improve the quality of the service and meet the regulations.

The service provides care and support for up to 21 older people, some of whom may be living

with dementia and chronic health conditions. On the day of our inspection, 18 people were being supported by the service.

Although the service has a registered manager in post, he has not been responsible for the day to day management of the service for a while. A deputy manager has taken on this role, but has not yet registered with the Care Quality Commission. This is in breach of the registration conditions as the registered manager was no longer managing the regulated activities for which they had been registered and had not formally notified us of the change. You can see what action we have taken against them at the back of the full version of the report. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were safe and the provider had effective systems in place to safeguard them. Staff had been trained to safeguard people and were able to identify when people required additional support. However, staff did not always take enough steps to protect people from possible risk of acquired infections.

There were personalised risk assessments in place that gave guidance to staff on how risks to people could be minimised. Risks associated with day to day running of the service had also been well managed.

People’s medicines were now being managed safely and administered by trained staff in a timely manner. However, the provider did not always order on time the equipment needed for other professionals to provide people’s treatment.

The provider now had effective recruitment processes in place so that people were supported by suitable staff. There was sufficient staff to support people safely and they had received supervision, support and effective training that enabled them to support people appropriately. The deputy managers and staff now understood their roles and responsibilities in relation to providing care in accordance with the requirements of the Mental Capacity Act 2005 (MCA) and the related Deprivation of Liberty Safeguards, and appropriate referrals had been made to the relevant local authorities.

People were supported to have sufficient food and drink. Assessments had been completed for people deemed to be at increased risk, but it was not clear how often these were done for everyone else. People were also supported to access other health and social care services when required and the provider had been responsive to the advice given by the local authority so that people received timely treatment when unwell.

People were supported by staff who were caring, kind and friendly. However, some people’s privacy was not always respected because staff sometimes used their bedrooms to support other people in private.

People’s needs had been assessed and care plans were in place. However these did not always take into account their individual preferences and choices. Activities were provided within the home, but it was not clear how people were supported to pursue their hobbies and interests or meet their religious or spiritual needs.

The provider had a formal process for handling complaints and concerns. They encouraged feedback from people and their relatives so that they had the information they required to improve the quality of the service.

The provider now had processes to assess various aspects of the service. However, they did not have a system that enabled them to bring this information together so that they could analyse it and monitor trends.

We carried out an unannounced comprehensive inspection on 17 July 2014. After this inspection we received concerns in relation to the care and welfare and safety of people who lived at the home. As a result we undertook a focused inspection to look into those concerns. This report only covers our findings in relation to those topics. 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.uk

Oak Cottage is registered to provide residential care for up to 21 older people, some of whom live with dementia. There was a registered manager in place however, they did not oversee the day to day running of the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider. The service was being run by three assistant managers, two of whom were available on the day of our inspection. However we did speak with the registered manager at the end of the inspection as part of the feedback.

The service provided a welcoming and a homely atmosphere. People told us that they were happy with the care and support they received. Staff knew people well and supported them appropriately. We observed that staff responded promptly to people’s request for help and support.

Care Quality Commission (CQC) is required to monitor the operation of the Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are put in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way, usually to protect themselves or others. At the time of the inspection there had been no applications made to the local authority in relation to people who lived at the service even though we were informed by the two assistant managers that there were people who lived at Oak Cottage who did not have capacity to consent. The manager and staff had very limited knowledge or understanding of their role in relation to MCA and DoLS.

Some areas of people’s care plans reflected individual needs and gave guidance to staff on how to support people. However, we also found that the care plans did not provide detailed information on how to care for some people’s care needs such the management of both pressure care and skin integrity and the spread of infection, nutrition, end of life decisions or a person’s ability to make decisions. People were not always involved in decision making about their care. Relatives were approached by the staff at the service who discussed and planned care with the management and staff team.

People did not always receive their medicines as prescribed and not all of the medication records required by legislation were up to date.

We found that the provider’s recruitment procedures had not always been followed. This meant that people were potentially put at risk of harm. Staff had not received appropriate and relevant training to be able to meet the needs of the people who used the service.

We found that there were no arrangements in place for regular ‘house’ meetings to be held. This meant that people were not given an opportunity to express their views on how the service was run or to raise any issues or concerns about the service provided.

At this inspection we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, and to provide a rating for the service under the Care Act 2014.

Oak Cottage is registered to provide residential care for up to 21 older people, some of whom live with dementia. There was a registered manager in place however, they did not oversee the day to day running of the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider. The service was being run by three assistant managers, one of whom was available on the day of our inspection and one we spoke with after our visit.

The service offered a homely feel. People told us that they were happy there and that the staff were kind and caring. Staff knew people well and supported them appropriately. We observed that staff were attentive and patient with people.

There were gaps in the recruitment procedures and also gaps in staff training. This meant that people could not be sure they were supported by safely recruited staff with the right skills and experience.

Some areas of people’s care plans reflected individual needs and gave guidance to staff on how to support people. However, we also found that the care plans did not include assessments for skin integrity, nutrition or a person’s ability to make decisions. People were not always involved in decision making about their care. Relatives were approached by the staff at the service who discussed and planned care with the management and staff team. Information about people, which included people’s care plans, was not stored securely. This meant that personal information was accessible to people who were not permitted to access the information.

The systems in place for monitoring the quality of the service were not structured. The management were unable to demonstrate that they undertook reviews of such areas as care plans, the environment and staff training. Ths meant that the service did not have effective systems in place to regularly assess and monitor the quality of the service to ensure that people were protected against receiving care that is unsafe or inappropriate.

At this inspection we found the service to be in breach of Regulations 9, 10, 11, 17, 21 and 23 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

We had previously inspected Oak Cottage on 18 July 2013. We had found that were not meeting the standards required for cleanliness and infection control and therefore carried out a further inspection on the 10 October 2013 to confirm that the home had taken the steps required to improve the standards of cleanliness and infection control.

When we inspected the home we found that it had completed all actions required and was now compliant with the regulations.

We visited Oak cottage on 18 July 2013. We found that people at the service were all well looked after and that their person care needs had been met. On arrival we saw that staff were offering people drinks in the main communal room and that some people were being cared for in their rooms. We were told that the home was a family run home and that because of this it had a 'family feel'. We were told that the care home seemed 'more like a home than an institution' and there was a 'relaxed atmosphere'. People also told us that they could 'come and go' as they pleased in the grounds of the home and that it 'doesn't smell'. People told us that 'the home is an ideal home run by a family who are genuinely nice people, who look after people' and that they made it a 'home from home' for people who used the service and their families.

While at the service we did find that the provider was not meeting the requirement under cleanliness and infection control within the laundry area of the home.

During our visit on 23 July 2012, we spoke with seven people who use the service and they told us that they were happy with the care and support they were receiving. They were complimentary of the food, the staff and the range of activities provided for them. Some people said that the food was 'very good and we look forward to lunch' but when we asked what they had ordered, they said they liked a surprise. They also said that the staff were respectful, caring and knew how to support them in meeting their needs.

All the people we spoke with said that they did not have any concerns about the care home. One person said 'its marvellous here. They can't do enough for you'. Another person said 'I have no complaints. They treat us well. They feed us well'.

Oak Cottage

All Inspections

During an assessment under our new approach

8 November 2023

During an inspection looking at part of the service

12 March 2019

During a routine inspection

12 July 2016

During a routine inspection

5 November 2015

During a routine inspection

23 January 2015

During an inspection looking at part of the service

17 July 2014

During a routine inspection

10 October 2013

During an inspection looking at part of the service

18 July 2013

During a routine inspection

23 July 2012

During a routine inspection