Oaklands Care Home

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 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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff understood when and how to report incidents. Incidents were investigated and reviewed to identify areas for change and any themes. Staff told us, “We try to promote actions that prevent incidents from happening again. Sometimes it’s trial and error so it’s the case of seeing what has and hasn’t worked and see if the situation changes.” Staff told us they were involved in identifying what had gone wrong and why, in order to learn lessons. For example, one staff member said, “There is a lessons learned section on the forms we fill out. It

discusses how the incident could have been prevented. [Registered manager] will also have achat with us about it.”

Lessons learned from incidents were shared with staff to prevent a recurrence. We saw records of these within daily meeting minutes. We also saw an example of a staff briefing following an incident whereby the manager and staff member discussed the incident, reflected on what happened and additional support was offered.

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, including when people moved between different services.

Pre-assessment tools were completed. One staff member said, “[Registered manager] will do the initial assessment, this is then passed straight over to the carers and the seniors. The information is put on the devices, and there will firstly be a paper copy for staff to read.”

Records showed people were referred to other healthcare professionals when needed. There was a weekly GP review and staff told us it was easy to contact a GP for advice between weekly calls. Records showed people were supported to attend appointments.

Staff told us they worked well with health and social care professionals and had developed good working relationships. There were clear processes to ensure people’s current information was safely shared.

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.

Everybody we spoke with told us they felt safe living at the service. One person said, “I have been here a long time, and the staff make me feel safe.” Overall people’s relatives told us they felt confident their loved ones were safe living at the service and had observed staff supporting people safely and kindly when they visited. One person’s relative told us, “[Name] walks with a walker and has had one fall in the home when [they] tried to walk without the walker and stumbled. Staff took [name] to the hospital, and when they discharged [name], the staff phoned me to tell me.”

Staff had received safeguarding training and knew how to raise concerns.

There were safeguarding and whistleblowing procedures in place. The management team understood their responsibilities regarding the action to take to protect people from harm. The necessary internal documentation was completed including accident/incidents logs and body maps. The provider ensured referrals and notifications were made to both the local authority and the Care Quality Commission in a timely manner.

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.

People had been assessed for risks such as skin damage, falls and choking, and when risks were identified care plans provided information for staff on how to reduce the risk of harm.

When people were having their food and fluid intake monitored, records showed people were given enough to eat and drink.

Some people experienced episodes of anxiety or agitation. In these instances, care plans provided clear step by step guidance for staff on distraction techniques which were known to help.

Care plans for people who were at risk of falls were detailed and provided information for staff on how to promote people’s independence whilst walking as well as how to reduce the risk of falls. One staff member said, “[Name] walks with a frame. Staff are mindful to be with [name] when [they] are walking around the home.”

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 registered manager told us there was an ongoing refurbishment plan in place. The environment was visibly clean and well maintained. Staff were able to report any maintenance requirements. Equipment that we looked at was fit for purpose. For example, wheelchairs and moving and handling equipment were in good condition and clean.

We reviewed records of checks carried out to ensure the premises were safe. This included gas, electrical and fire safety checks. Regular checks of equipment were carried out. Personal evacuation plans were in place. These had been regularly reviewed to reflect people’s support needs in the event of needing to evacuate the building in an emergency.

There was clear signage throughout the building on doors, as well as signage providing directions to the lounge for example. Clear fire signage was in place around the building.

During our inspection we noted some action was needed regarding replacement of one window restrictor and one falls mat. The provider took immediate action to make the changes needed.

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.

None of the people we spoke with raised concerns about staffing levels. One person said, “The staff are good and there when you need them. If I go out into the garden, they are always there to check I’m OK.”

Overall, people’s relatives told us they felt there were enough staff on duty to meet people’s needs with comments such as “[Name] doesn’t remember what the bell is for, so they do check on [name] and when I go and visit, they know where [name] is. When [name] needs help, they [staff] come quickly. I feel they are on the ball, and they seem to genuinely care about the residents and their needs.”

Staff received effective training, support, supervision and development. One staff member said, “Supervisions are around ten times a year, they come around so quickly. They do appraisals as well. I openly vent to [registered manager] about things that could do with some improvement or if they’re not working, and she always listens.”

All required recruitment checks were in place prior to staff starting to work at the home. There was a system in place to ensure there were sufficiently skilled and experienced staff deployed. People were supported by a consistent staff team, who had worked at the service for long periods of time and knew them very well. Staff we spoke with gave mixed feedback about staffing levels. Some staff told us they felt there were enough of them on duty and other staff felt there weren’t, although all staff told us the management team were available to help with supporting people if needed. During the inspection, we observed staff were visible throughout the building, did not appear rushed and were able to respond to people’s needs in a timely manner.

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.

There were audits in place to oversee the cleanliness and safety of the environment. The service was visibly clean and tidy. People and their relatives told us the housekeeping staff were on duty every day. For example, one person’s relative said, “Yes, they are always cleaning, if someone makes a mess, they clean it up.”

There was handwashing signage and facilities throughout the building. Staff had received infection control training and told us when and why they needed to wear personal protective equipment. Regular handwashing checks were carried out.

There were appropriate clinical waste facilities and colour coded cleaning materials. Food safety was maintained. Kitchen monitoring checks were in place. We saw 2 side tables, a falls mat and a commode lid that were worn and would be difficult to keep clean to prevent cross contamination. We fed this back to the registered manager and replacement items were ordered before we left the service.

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

Although the temperature of the medicines storage area was monitored, records showed the temperature was recorded as over 25 degrees Celsius on 29 occasions since January 2025. The temperature monitoring chart informed staff to “consider using a fan or air-cooling unit” if the temperature exceeded 25 degrees; however, staff had not documented any action taken or if the action had been effective in lowering the temperature. The provider’s medicines policy stated, “The temperature of the room in which the medicines are stored must not exceed 25 degrees Celsius” and “Any senior staff member receiving a report of abnormal temperature readings must make immediate arrangements to bring temperatures down.” We discussed this with the management team during the inspection and an air-cooling unit was purchased and put in place on day 2 of the inspection and the temperature monitoring chart was updated to include a column for staff to document any action taken. We received further assurances from the provider that they had purchased new equipment to support with room temperature management. Medicine audits we looked at had not identified temperature monitoring as an issue.

Protocols for medicines that had been prescribed on an as required [PRN] basis were person centred and informed staff when and why people might need their additional medicines. When PRN medicines had been administered by staff, although there was information recorded to show why they had been administered, staff had not always recorded the effectiveness. This meant it would be difficult to assess how well medicines were working. The registered manager told us a reminder had been sent to staff to document this.

Medicine administration records (MARs) were signed to indicate people had received their medicines on time as prescribed. Good stock control was maintained. Bottles of medicines, including creams and lotions had been dated when opened, so that staff would know when items had expired. Staff recorded when creams and lotions were applied.

There were risk assessments in place to identify those people prescribed anti-coagulants. Records show people had their medicines reviewed, including the use of anti-psychotics and sedation for example.

Staff who administered medicines had received up to date medicine training and had their competency checked.