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CQC report explained · a residential care home, run by Chaseview Enterprises

Oak Tree House

68 Sevens Road, Cannock, WS12 0QA

Requires improvementpublished 18 January 2024, 2 years ago

Rated Requires improvement: inspectors found the service was not performing as well as it should and told it what to change.

The five questions inspectors ask
Safe?
Good
Inspectors found enough staff, updated risk assessments, appropriate safeguarding referrals, safe medicines management and good infection control. They recommended that relevant previous social care employers should be contacted for references.
Effective?
Requires improvement
This question was not assessed during this focused inspection. Its previous rating was used when calculating the overall rating.
Caring?
Requires improvement
This question was not assessed during this focused inspection. Its previous rating was used when calculating the overall rating.
Responsive?
Requires improvement
This question was not assessed during this focused inspection. Its previous rating was used when calculating the overall rating.
Well-led?
Requires improvement
Inspectors found improved care planning, staff meetings and quality checks, but leadership was inconsistent. Recruitment checks, safeguarding knowledge and systems for managing complex risks were not yet sufficiently reliable or embedded.
The latest report, explained

What inspectors found, January 2024

Oak Tree House is rated Requires Improvement; inspectors found safe care but inconsistent leadership and systems that were not yet fully embedded.

This was an unannounced focused inspection. Inspectors visited on 29 November and 5 December 2023, spoke with people, staff, relatives and managers, and checked care records, medicine records, staff files and quality checks.

The home was rated Good for Safe. People told inspectors they felt safe. Staffing, risk assessments, safeguarding, medicines, infection control and learning from incidents had improved. The provider was no longer in breach of the staffing or safeguarding regulations from the previous inspection.

The home was rated Requires Improvement for Well-led. Inspectors found mixed views about the registered manager's visibility and responsibility. Checks of recruitment and risk management were still not reliable enough, and improvements needed more time to become fully established.

The overall rating remains Requires Improvement. This was the second consecutive inspection with that rating. The ratings for Effective, Caring and Responsive were not assessed during this focused inspection and were carried over from the previous inspection.

What inspectors praised

  • People felt safe

    People told inspectors they felt safe, and staff understood their individual risks and how to reduce them.

    “People were supported by staff who knew them well and knew how to meet their needs and manage risks.” from the report

  • Safe medicines

    Medicines were stored and given safely. Staff followed guidance for medicines given only when needed, including the principles of STOMP.

    “Medicines were stored and administered safely. The principles of STOMP (stop over medicating people with learning difficulties) were applied when people were prescribed 'when required' medicines.” from the report

  • Improved care planning

    Care plans had been reviewed with people who wished to take part, and people were taking part in more activities they chose.

    “The provider had placed more emphasis on making care person centred and empowering people.” from the report

  • Learning from incidents

    The provider had introduced processes to review accidents and incidents, identify learning and share it with staff.

    “Where accidents and incidents occurred, the registered manager reviewed them and identified any learning, which was then shared with staff.” from the report
What inspectors were concerned about

  • Leadership was inconsistent

    needs fixing

    Staff and relatives gave mixed feedback about the registered manager's visibility and responsibility. Inspectors said the positive changes needed more time to become fully established.

    “Staff and relatives were not always clear about the role of the registered manager and did not always find them to be visible.” from the report

  • Risk systems were not fully embedded

    needs fixing

    Inspectors could not yet be assured that risk systems would be sufficient when supporting people with complex needs and risks.

    “Systems in place to manage risks had not yet been sufficiently embedded.” from the report

  • Recruitment checks had gaps

    minor

    One staff file did not show that a previous social care employer had been contacted. Other recruitment checks also did not always identify missing risk assessments.

    “Quality checks of recruitment records did not always identify gaps.” from the report

  • Safeguarding knowledge needed improvement

    needs fixing

    The registered manager's understanding of where safeguarding referrals should be sent was not always correct. Other managers supported the service so referrals were submitted appropriately when needed.

    “The registered manager's knowledge regarding safeguarding procedures was not always adequate.” from the report
Questions to ask them, based on this report
  1. 01How are you making sure the registered manager is visible, takes responsibility and is available to families and staff?
  2. 02How do you check that risk assessments remain suitable if a resident's needs or risks become more complex?
  3. 03How do you make sure previous social care employers are contacted for references before staff start work?
  4. 04What action has been taken to improve the registered manager's safeguarding knowledge?
  5. 05What evidence can you show that the improvements identified by inspectors are now fully embedded?

This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried over from the previous inspection. This explanation was written from the published report of 18 January 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.

The story over the years

Every inspection of Oak Tree House

4 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.

  1. January 2024Requires improvementcurrent ratingstayed Requires improvement
    Safe: GoodEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement

    Read what inspectors found at Oak Tree House →

  2. September 2023Requires improvementdown from Good
    Safe: Requires improvementWell-led: Inadequate

    We are reading this report · the original is on cqc.org.uk

  3. March 2018Goodstayed Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read this report on cqc.org.uk

  4. March 2016Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read this report on cqc.org.uk

  5. February 2015

    Registered with the Care Quality Commission on 4 February 2015.

Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.

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