Red Oaks Care Community

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 requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to safe care and treatment and premises and equipment.

This service scored 34 (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 always demonstrate a proactive approach to learning from safety events. Systems for investigating incidents and complaints were inconsistent, and lessons were not always shared with staff to prevent recurrence. While staff felt supported and able to raise concerns, there was limited evidence of structured debriefs or improvements following incidents. Audits failed to identify key risks such as unsafe equipment and poor infection control, indicating gaps in organisational learning. The provider did not follow the recommended actions, from an external report in relation to pressure care.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They 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.

Processes to ensure continuity of safe care were not always effective. Care records contained contradictions, and risk assessments lacked detail for high-risk interventions such as anticoagulant use and stoma care. Failure to have accurate and up to date care notes placed people at increased risk of information being shared not being accurate during transitions in their care. Transitions into the service were managed, but oversight of ongoing risks was poor. People had access to emergency grab packs containing information to support people with unexpected visits to hospital. While healthcare partners were involved in care, internal systems did not consistently support safe pathways.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and

appropriately.

Although staff understood what abuse was, there was no information available to them on who to contact in the event of a concern. Staff told us they would have to search the internet to find out how to report abuse. We saw the information available to people, staff and visitors regarding safeguarding did not contain information on how to report concerns. The provider’s available safeguarding policy stated “insert here local SG protocol,” and the provider’s whistle blowing policy available in the communal area for people to refer to stated “enter your local authority here”. The documents failed to provide details on how to raise concerns. We checked the available staff information boards and were told the relevant information on how to raise concerns had been removed. This could potentially have hampered people’s ability to raise concerns in a timely way. There had been a lack of safeguarding notifications for some people. For example, a person was admitted into the home with no care plan in place and upon hospital admission several pressure areas were identified. The lack of a care plan and failure to identify or act on grade 3 pressure sores put the person at the risk of avoidable harm.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found appropriate assessments and applications had been made in line with the recommended procedures whilst still supporting people to live the lives they wanted. Any restrictions in place were authorised, proportionate and the least restrictive.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care plans were in place, but they contained inconsistencies and omissions, such as unclear guidance for choking risks and mobility support. Staff were observed managing behaviours of distress effectively.

Nutrition care plans did not always provide sufficient information. For example, a person was at a high risk of choking as they ate very quickly and we were told that because of this someone must sit with them at mealtimes. Although we observed staff present, the person’s nutrition and hydration plan did not provide those details. This placed the person at an increased risk of harm through choking.

Continence care plans did not always provide sufficient information. For example, 1 person had a stoma in place and a care plan was available however, the care plan failed to provide guidance on the frequency of bag changes, how to monitor the stoma site for infections or inflammation or how to clean the stoma site. This placed the person at an increased risk of harm.

People’s care plans contained contradictions and gaps. For example, a person’s mobility plan stated they could walk short distances, while their falls risk assessment recorded they were hoisted for all transfers. Wound care plans also conflicted with repositioning instructions. Inconsistency in care plans put the people at the risk of harm as staff would not have clear direction on how to safely support them. Since bringing these issues to the providers attention, alterations have been made to people’s care plans where we highlighted discrepancies.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The environment was not consistently safe or well maintained.In 1 bathroom an electrical cable was unsecured along the edge of the floor which posed a potential trip hazard.There was open access to potentially hazardous substances in 3 separate areas of the building including, substances which could cause eye damage. There was a container of drinks thickener left unsecured in a communal area and superglue and staff medication left on the hydration and nutrition station. These were immediately handed to management by the inspectors. People living with dementia could access these areas which presented a risk of harm from contact or accidental or intentional digestion.

We observed 2 uncovered radiators that were hot to the touch. Once brought to the providers attention 1 radiator was addressed during the visit and assurances were received that the other radiator would be turned down.

Water temperatures exceeded safe limits, posing a scalding risk. Despite raising this with the provider, and them checking and confirming the temperature, the bath still ran excessively hot the following day. We asked staff members whether they had received any information or warning about the bath but none were aware of any issue. This put people at the risk of scalding from contact with hot water.

Not all windows had tamper-proof restrictors, increasing the risk of falls from height. The provider immediately ordered the correct screws once brought to their attention.

Ongoing building work was taking place in an unregistered area of the building, yet 2 people independently accessed it. Tools and heavy objects, including an unsecured fire door left upright, were unattended for prolonged periods. These presented a risk of harm to those who had open and unrestricted access to this area.

We saw people were being supported with wheelchairs which had not been maintained to a safe standard. Heel straps were either missing or broken and in 1 instance a person was being supported with both feet on one foot plate. These issues put people at the risk of injury.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

People were supported by staff who had been safely recruited, with appropriate checks in place. Staffing levels were generally sufficient, and staff were observed responding promptly to people’s needs. Staff felt supported and had access to training, including safeguarding and fire safety.

Two nurses’ medication competencies had expired, and they had continued to administer medicines, which compromised safe practice. Once brought to management attention, they told us they were already aware of this. They stated that this was going to be completed the following day.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading.

We found widespread poor infection prevention and control practice. One relative said, “No, it’s not at all clean.” They described their relatives clothing being dirty when it had come into contact with the floor. High frequency touch points contained evidence of debris. Doors, handrails and furniture had been poorly maintained and contained exposed filler. These issues hampered effective cleaning practices. Some over chair tables showed evidence of dried fluids indicating poor cleaning practice. Bathroom extractor fans contained significant build-up of what appeared to be dust or powder presenting a risk of airborne contaminates as well as a fire risk. The extractor fans were addressed by the provider during the inspection once highlighted. Wheelchairs were visibly dirty in places increasing the risk of cross infection. The floor sealant around a bath was compromised which hampered effective cleaning.We observed several broken pedal operated bins which posed an infection prevention and control risk. Once brought to the providers attention, new bins were ordered immediately.

We observed some equipment intended for individual use, such as hoist slings, were shared between people. They were used as a toileting sling without cleaning between people on both days of our visit. These failings placed people at significant risk of infection.

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.

Medicines were not always managed safely. While storage arrangements were secure and temperature checks were completed, some PRN ‘as required’ protocols lacked person-centred detail, and controlled drug stock checks were overdue. Care plans did not consistently include information about prescribed medicines or associated risks. For example, there was no risk assessment for high-risk anticoagulants. These gaps increased the risk of errors and unsafe administration. Since our inspection the provider has made changes to improve some PRN protocols that were highlighted.