Archived: Waltham House Limited Also known as Oasis Care

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The provider did not hold regular staff meetings to share feedback. The registered manager told us staff were kept up to date when people’s needs changed, through encrypted group chat messages. However, we found systems to record accidents and incidents were not robust and were not routinely shared with staff to support lessons learnt. One staff member told us, “It’s all done over the group chat we are in”.

The provider did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Staff told us how they supported people to deliver safe care and support. Comments from staff included, “We are all on a [mobile messaging app] and emails are password protected, we read the file which is in a person’s home, that has the care plan in” and “We do the referrals ourselves to the district nurse, we have a speed dial for the district nurse and update in the book, and the [mobile messaging app]”. While staff supported people well and monitored their individual needs recording systems were not robust and risk assessments were not in place. This meant we could not be assured of continuity of care or safe pathways for people.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Systems and processes were in place to ensure people were protected from abuse and avoidable harm. Staff had received safeguarding training and knew how to report a concern.

The provider did not always work well with people to understand and manage risks.

Care plans did not always provide sufficient guidance on how staff should safely support people. Staff were provided with daily tasks via a mobile app which provided instruction on how to support people at each visit. Risks to people were not always assessed. One staff member told us, “A lot don’t have risk assessments to be fair, currently none have risk assessments”. People who were at increased risk of skin breakdown did not have nationally recognised tools in place to guide staff in identifying deterioration in a person's skin. People had not been affected by the risks identified; however, we could not be assured the service had effective risk management in place.

People were not fully protected from environmental risks because key safety assessments had not been completed, however people told us they knew who to contact to raise a concern.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support. They worked together well to provide safe care that met people’s individual needs.

There were enough staff to meet people’s needs. Staff told us there were enough staff and that they were supervised regularly in their roles. People told us they were happy with the staff who supported them. Comments included, “They know what to do, I think they are very well trained”, “They are very competent” and “Perfectly safe, they are very caring and they notice if things are not quite right”.Safe recruitment processes were in place and the registered manager carried out regular supervisions and spot checks to support staff in their role.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.Leaders were committed to ensuring staff maintained high standards regarding infection, prevention and control. Personal protective equipment (PPE) was readily available for staff and people confirmed staff always wore it. Staff feedback included, “We have [enough PPE], if we run out we can collect from different locations from the office for example, and extra in the pack.” Feedback from people included, “They wash their hands and wear gloves. They wear gloves when they dress me, take them off and wash their hands and then make my tea”.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

The provider was supporting 1 person to administer their medicines. Medicine administration records (MARs) were being used to confirm the administration of medicines by the care staff. However, information recorded in the provider’s MARs was not of a sufficient quality to meet national guidance. The MARs for January 2026 had not been signed by any of the care staff, so the provider was unable to show that the person concerned was receiving their treatment as specified by the prescriber. There was no detailed assessment to determine what support this person required to take their medicines. Supporting information to assist staff did not describe who was responsible for the ordering, collecting and storage of medicines, and did not accurately reflect the MARs, or identify the risk associated with one of the medicines.