Oaklodge 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

This means we looked for evidence that people were protected from abuse and avoidable

harm. At our last inspection we rated this key question requires improvement. At this inspection

the rating has remained 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 was in breach of legal Regulation 17, good governance. This was in relation to

oversight of the service.

This service scored 56 (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.

The registered manager would investigate and share lessons learnt with the team when

incidents or accidents occurred, or concerns were raised. Clear instructions were provided to the

team on how to implement different or new practice going forward. For example, there was a

recent incident where a Thermostatic Mixing Valve which is designed to regulate the water

temperature failed during someone’s shower, which led to scalding. Although not an error of the

service and deemed an unfortunate event, the registered manager implemented a new process

to prevent a similar incident occurring in the future. This was shared with staff via multiple

methods of communication to ensure it reached everyone.

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. People’s care plans were not formulated in a coherent way which would enable services to provide peoples care effectively or in line with their preferences. Care plans did not reflect how people currently receive their care and contained information that was out of date and no longer relevant. The provider had a system of keeping people’s information readily available for emergencies, for example, being admitted to hospital, fire or evacuation of the home. However, the provider had not ensured all people’s records were included or that all the information had been updated to reflect people’s current needs. We brought this to the attention of the provider who rectified this before our assessment was concluded.

The provider worked well with people and healthcare partners to understand what being safe

meant to them and how to achieve that. They concentrated on improving people’s lives or

protecting people from avoidable harm and neglect.

The provider had appropriate safeguarding policies, procedures and training in place. People

and relatives could easily access information on how to recognise and raise concerns internally,

or to external organisations as it was displayed in various places around the home.

Staff were confident in recognising and responding to concerns. Staff were also confident that

the registered manager would act upon their concerns.

Learning was applied following incidents or safeguarding events, to prevent reoccurrence. There

was some room for improvement around documentation provided by staff to ensure the incident

record was clear and coherent.

People told us they felt safe, and relatives were confident in the staff and leaders to keep their

loved ones safe.

There was some additional training needed in relation to safeguarding children. The service

occasionally had some children from a nursery visit the home, but staff were not trained in how

to identify and report child abuse. The provider had completed a risk assessment to ensure the

safety of the children whilst they were present at the

service.

The provider ensured that where people could not consent to their care or treatment, they were protected by the Deprivation of Liberty Safeguards (DoLS) and applied for a DoLS promptly when the need arose.

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

always provide care to meet people’s needs that was supportive and enabled people to do the

things that mattered to them.

People were not always involved in assessing and managing their risks to achieve goals or

aspirations that mattered to them and were not included in exploration of new activities in and

outside the home. This affected those people who could not always communicate clearly.

However, people who could express themselves reported that they were overall happy with their

care, For example, one person attended a day centre, and despite challenges, the staff and

registered manager continued to support them to go, as it was a meaningful activity for the

person.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. People were not always protected from the risk of harm from accessing items that could burn or scald them, or from cleaning chemicals and equipment as the door lock on the kitchen door was not fit for purpose. People were placed at higher risk of trips and falls from moving and handling equipment protruding into the hallway. Not all hot water pipes and radiators were covered to protect people from hot surfaces. These had not been identified in the provider’s environmental checks. We brought these issues to the attention of the provider who arranged for all these areas to be made safe immediately and update their environmental checks. Some fire exit signs had not been updated with the new fire assembly point, however, there were no other concerns with their fire safety processes, checks and procedures.

The provider did not always make sure there were enough qualified, skilled and experienced

staff. The provider used a dependency tool to work out what level of staffing was required. They

operated in line with this tool; however, we were not assured that the deployment of overnight

staffing was

sufficient

.

The provider did not ensure staff who administered medicines at night had received medicines

training and had their competencies checked by a suitable trainer. We brought this to the

attention of the provider who said they were sourcing training for senior care staff, and the

registered manager which would qualify them to train and assess the competency in medication

administration. People received care from staff at night who had not been suitably trained to

carry out aspects of the role of a senior

carer

, and there was no provision of qualified senior staff

during nighttime hours.

The provider operated an on-call system where staff could get support and advice from a

manager or senior carer out of normal working hours which was being utilised.

Relatives told us they were happy with the staff at the service, one person said, “The staff are

outstanding”.

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 no recent outbreaks of infectious diseases within the service. Staff reported being

provided with sufficient personal protective equipment (PPE) provisions, such as disposable

gloves and aprons. We saw staff using PPE appropriately.

Staff told us, and records showed domestic staff had enough time and resources to complete

the cleaning schedules.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning. The provider did not ensure there were sufficient policies and procedures for the safe management of people’s medicines. People were at risk of not receiving their medicines safely or as prescribed. Where people received ‘as-required’ medicines, staff did not have the information they required in the form of protocols to know when to administer these, or what the maximum dose of medicines were. People’s medicine administration records were not always clear as staff had recorded handwritten entries which were not legible. Staff failed to follow the medicines procedure as they did not use the key codes for actions they had taken. The provider failed to have a policy or protocol for over-the-counter medicines (homely remedies). People were at risk of not receiving medicines safely as staff administered medicines that could be readily purchased from a shop that had not been prescribed, without any guidance. The provider’s medicines audits carried out by the registered manager and senior staff were not effective as they had not identified any issues.