Red Oaks Care Community

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• 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 inadequate. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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 demonstrated a more proactive and positive culture of safety since our last assessment. Incidents and complaints had been investigated consistently, and lessons learned were shared appropriately with staff to support continuous improvement. The appointment of a new manager had strengthened oversight and governance arrangements within the home. Staff told us they felt supported to raise concerns and contribute ideas for improvement. One staff member said, "Managers are now supportive, and they want us to let them know if something is wrong."

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, this included when people moved between different services. Since our last assessment, care plans had been reviewed and updated to ensure staff had clear guidance on people's care and support needs, this included specialist healthcare tasks such as catheter care. The operations manager told us they continued to review and develop care plans to promote a more person-centred approach and increased people's involvement in planning their care. Systems were in place to support safe transitions between services and help ensure continuity of care when required.

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.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. Where people receive support in their own homes, this can be done through The Court of Protection which is defined as 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 deprivation of liberty within the service. We found that the principles of the MCA were being met and care plans contained detailed assessments of people ability to make informed decision and clear guidance for staff.

Staff were knowledgeable about risks people faced and raised concerns to managers where needed. One staff member said, “I report all concerns to [manager] and they are very good and take action straight away.” We saw evidence of concerns being shared with CQC and the local authority appropriately.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Since our last assessment, care plans had been updated to provide staff with clear guidance on how and when to support people safely. This included detailed information relating to nutritional needs and identified risks associated with choking. Staff demonstrated a good understanding of these risks and described the measures in place to reduce them. During our assessment, we observed staff providing care and support in a safe manner that reflected people's assessed needs and preferences.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The provider had made improvements to the safety of the environment since our last assessment. Water temperatures were maintained within safe limits and were monitored regularly. Areas used for storage, including those containing hazardous substances, were secured and inaccessible to people living at the home. Equipment, such as wheelchairs and pressure-relieving cushions, were clean and subject to regular checks and audits to help ensure it remained safe and fit for use.

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

Staff had been recruited safely, and appropriate pre-employment checks, including Disclosure and Barring Service (DBS) checks, had been completed. Staff completed mandatory training and received regular competency assessments to help ensure they had the required skills and knowledge to provide safe care.

There were sufficient numbers of staff deployed to meet people's needs and preferences. People told us they generally received support when needed and did not experience significant delays. One person said, "Yes, there is enough staff. They are very busy, but they will always help you with whatever you need."

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.

The provider had made improvements in relation to infection prevention and control since our last assessment. Domestic and maintenance staff worked effectively together to maintain a clean, safe environment and reduce identified risks. We observed that communal areas and people's bedrooms were clean, tidy and well maintained. Staff demonstrated a good understanding of infection prevention and environmental risks and took appropriate action to address them. For example, we observed maintenance staff replacing worn emergency pull cords in bathrooms to support effective cleaning and infection control measures.

The provider had made improvements to medicines management; however, further work was required to ensure medicines records and care plans consistently supported the safe administration of medicines and reflected people's individual needs.

The provider had strengthened oversight of medicines management through the appointment of a clinical lead. Staff spoke positively about the support they received and described having access to guidance and advice when needed. One staff member told us, "Now that we have a clinical lead at Red Oaks, I feel well supported and know I can ask for clear guidance or clarification if I am unsure about a certain area of practice."

However, further improvements were required to ensure medicines records and care plans consistently reflected people's needs. For example, where people were prescribed time-critical medicines for Parkinson's disease, the required administration times were not always clearly recorded within care plans. The provider identified this during the assessment and took immediate action to seek clarification from the person's GP and update records accordingly.

We also found guidance for staff relating to 'when required' (PRN) medicines did not always contain sufficient detail. In some cases, records did not clearly describe the circumstances in which medicines should be administered, expected outcomes, or potential side effects. Although we found no evidence that people had experienced harm as a result, these omissions increased the risk of inconsistent medicines administration.