The Oaks Care Home

Updated 5 September 2025

Date of assessment: 10 and 26 September 2025.

The Oaks Care Home provides residential and nursing care for up to 45 people. At the time of this assessment there were 31 people living in the home, some of whom were living with a dementia.

We carried out this assessment because we received concerns from the local authority, integrated care board (ICB) and local NHS infection control team about people’s care and support, the environment, infection control and the management of the home.

At our previous 2 inspections, the provider had been in breach of the legal regulations in relation to safe care and treatment and good governance. At this assessment, not enough action had been taken to improve and the provider remained in breach of these regulations. We also found an additional breach of the regulations relating to person-centred care.

There had been no registered manager in post since July 2024. An interim manager was in place at the time of our assessment. Staff, people and relatives spoke positively about them. A new manager had been recruited and was due to start following our assessment.

Risks relating to people’s care and support were not always effectively assessed, recorded, monitored and managed. Information regarding people’s nutrition and hydration, falls management, catheter care and positional changes to reduce the risk of pressure ulcers was not always accurate or detailed.

Records did not always evidence that an effective system was in place to ensure medicines were safely administered, stored and managed.

Action was being taken following the ICB, local authority and the local NHS infection control practitioners' visits in relation to the cleanliness of the home. When we visited, the home was cleaner, however, areas of wood and paint work were not intact which made it difficult to keep clean. Certain areas of the home, including several people’s bedrooms were malodourous. New non-slip flooring was going to be fitted in many of the carpeted rooms.

Prior to our assessment, training, supervision and appraisal meetings had not been carried out as planned. Training was being organised and carried out and a new supervision and appraisal planner had been implemented.

The home was in organisational safeguarding. This meant the local authority was monitoring the home and supporting them to ensure the correct procedures were in place to keep people safe. The provider put a voluntary suspension on admissions to the home to allow improvements to be made ensure people’s safety.

The provider had formulated an action plan prior to our assessment and updated it during and following our site visits and those visits carried out by the local authority and ICB, to ensure improvements were made.

A system to ensure regulatory requirements were met was still not in place. This was the third consecutive inspection the provider has been in breach of the regulations. There were shortfalls across the service in relation to medicines management, the environment, staff support and training, meeting people’s social needs, nutrition and hydration, the assessment of risk and record keeping.

We will request an action plan and meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good.

Updated 5 September 2025

Relatives spoke positively about the caring nature of staff. Comments included, “It's quite a small home and it is warm, and the staff are friendly,” “I am happy 100% with the care she receives. I go every day and always made feel very welcome” and “She always looks happy, and the staff love her - they always have a chat to her.” A relative took time to write a letter to CQC to provide positive feedback about all aspects of the home.

However, not all feedback was positive in areas such as the environment, staffing levels, the use of agency staff, nutritional support and meeting people’s social needs.

Whilst relatives told us staff were caring; we found the condition of the environment, including the outside space and cleanliness did not fully demonstrate that the provider fully respected people's privacy, dignity and wellbeing. A relative said, “The place is run down, and the gardens are a disgrace, it’s not a good environment for anyone to live.”

We received mixed feedback from relatives and staff, about whether there were sufficient staff to care for people and ensure the home was clean. Some felt that more domestic staff, especially at the weekend and more care staff at night, would be appreciated. The interim manager told us staffing levels were under review and the number of day staff had already been increased. Agency staff were used. People and relatives told us the permanent staff were knowledgeable about people's needs. However, they were not as positive about the skills of the agency staff. A relative said, “To be honest the regular staff are great, but the agency staff could do with the training.”

We observed the mealtime experience. Staff provided support in a calm unhurried and caring manner. We saw however, that staff did not support 1 person to have a drink in line with their care plan. There was no separate menu for people who required a modified textured diet.

We received mixed feedback from relatives about staff support at mealtimes. One relative told us, “She is very fussy with her food, but they encourage her to eat, she prefers puddings;” however, another relative said they had raised concerns around nutrition and staff support.

There was a lack of meaningful activities to support people’s social needs and emotional wellbeing. During our first visit, most people sat in the lounge with the television on. People were not actively engaged and spent a lot of time asleep. A relative told us, “Since being in there, there is no stimulation at all, no activities go on, they say they are arranging for activities.” A singer attended on our last visit to the home; people were actively engaged in the music and entertainment.

An effective system was not fully in place to enable people and relatives to share feedback and ideas or raise complaints about their care and support. The provider’s computerised system did not enable the monitoring and analysis of concerns and informal complaints to identify any trends. Senior management staff told us that this would be addressed.