Oak Tree Manor
Social Care Org · East
Overall Rating
Last inspected 10 April 2018
Domain Ratings
Safe
Effective
Caring
Responsive
Well-led
18 should-do actions
Should-Do Actions (18)
Recommended improvements to enhance service quality.
Should Do
Safe
Accidents and incidents needed to have remedial actions taken recorded and a system for identifying themes and trends needed to be developed to ensure it was robust.
Should Do
Safe
The records in relation to risk management was an area that required further development.
Should Do
Safe
Staff knowledge in relation to evacuation in the event of a fire needed to be improved.
Should Do
Safe
There were no plans in place for medicines prescribed on an as needed basis and some dates on eye drops had expired. This was an area that required improvement.
Should Do
Effective
Most people were supported in accordance with the principles of the Mental Capacity Act 2005, however, documentation needed improving.
Should Do
Effective
Although there was a menu on the wall of the dining room, this was not especially visible to people and there was no reminder to people prior to lunch being served.
Should Do
Effective
Fluid charts did not include targets for the amount people to drink or a tally of what people had consumed.
Should Do
Responsive
Care plans needed to be reviewed in more detail to reflect what staff knew about people and how the supported them. In some cases, they required more information. For example, in regards to sling size and straps for hoisting, if a person needed to have their legs elevated.
Should Do
Responsive
When supporting people living with dementia they may need to consider being more creative for people who had become more of a challenge to get engaged in activity and communication to avoid social isolation.
Should Do
Responsive
The service may benefit from having this [complaints process] in an easy read, more accessible place for people who may not look in the folders.
Should Do
Responsive
We discussed with the management team the need to capture people's voice within the notes from the meeting to demonstrate suggestions were considered and acted upon.
Should Do
Well-led
whilst information on for example falls had been recorded it did not link to any action being taken.
Should Do
Well-led
Equally for fluid charts the optimum amount of fluid for people was not recorded nor the amount for each day added up.
Should Do
Well-led
There were medication audits but like the other audits they did not pick up on the areas identified at the inspection.
Should Do
Well-led
However, these did not always identify areas that needed developing further. For example, issues in relation to MCA and best interest.
Should Do
Well-led
We could not find where these [actions arising from operations manager visits] were signed and dated when completed.
Should Do
Well-led
However, we noted that the notes for these meetings did not include a record of discussion or staff voice. This was an area that needed to be developed to ensure all feedback and ideas were captured.
Should Do
Well-led
However, we could not be sure that we had been informed the CQC of significant events in a timely way which meant we could check that appropriate action had been taken. This was an area that required monitoring.
Location Details
CQC ID: 1-111988217
Local Authority: Hertfordshire
Region: East
Inspection Report
Type: Comprehensive inspection
Date: 10 April 2018
Rating: Requires Improvement
Actions:
18 should-do
AI-extracted 17 Feb 2026