Oxenford House

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 remained as good.

This meant people were safe and protected from avoidable harm.

This service scored 75 (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 promoted an open and honest culture where safety concerns were identified, investigated and used as opportunities for learning and improvement. Staff understood how to recognise, escalate and report incidents and told us learning from events was regularly discussed during handovers and team meetings. One staff member said, “If I discovered a medication error, my first priority is the person's safety and wellbeing.”

Incidents were appropriately managed and investigated, with actions taken to reduce the risk of recurrence. Following falls, staff reviewed risks and introduced measures such as sensor beam technology, low-profile beds and enhanced monitoring arrangements to support people's safety while maintaining their independence. For example, after a person experienced 2 falls within 2 weeks of admission, staff implemented an alert system to notify them when the person attempted to get up at night.

Records showed the provider acted openly and transparently when incidents occurred. Following a medicine incident involving time-critical medicine not accompanying a person on an outing, staff informed the GP, apologised to the person and their family, completed observations and shared learning with the wider team.

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-admission assessments were comprehensive, person-centred and focused on ensuring people's needs, preferences and aspirations could be met safely and effectively. Managers gathered information from people, relatives and healthcare professionals and, where possible, visited people in their current environment to gain a thorough understanding of what mattered most to them. This enabled personalised support to be planned before admission and helped people feel confident about moving to the service.

The provider was particularly committed to ensuring people experienced a smooth and positive transition into their new home. People considering a permanent move were offered opportunities to access respite stays and regular visits before admission. This enabled them to become familiar with the environment, develop relationships with staff and other people living at the service and experience daily life within the home at their own pace. Staff recognised that moving into a care setting can be a significant life event and tailored transition plans to reduce anxiety and build confidence.

Relatives consistently told us this approach had a positive impact on people's wellbeing and helped them make informed decisions about their future care. One relative said, "My family member stayed for respite several times before moving in permanently. They got to know the staff, joined activities and made friends. By the time they moved in, it already felt like home." Another relative told us, "There was never any pressure. They were given plenty of opportunities to visit and experience life here, which reassured the whole family that it was the right place."

The provider worked proactively with people, relatives and health and social care professionals to coordinate transitions and ensure continuity of care. Care plans, risk assessments and personal preferences were reviewed regularly and updated following changes in need, including after hospital admissions or periods of respite. Managers were transparent about whether they could safely meet a person's needs and worked collaboratively with families to achieve the best possible outcomes.

When people moved between services, staff ensured detailed information about their health needs, communication preferences, routines, life history and personal wishes accompanied them. Staff frequently supported people during transfers or hospital admissions to provide reassurance and share important information with healthcare professionals. This helped ensure people experienced seamless, person-centred care during periods of change.

Feedback from people, relatives and professionals was overwhelmingly positive. They consistently described transitions as well-planned, highly personalised and focused on achieving the best possible outcomes. As a result, people experienced reduced anxiety, settled more quickly into their new home and developed meaningful relationships before permanently moving into the service.

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 told us they felt safe living at the service and had confidence in staff to support them when needed. Comments included, “I feel very safe here”, “It is a safe place” and “They come quickly when I ask for help.”

Relatives spoke positively about the provider's open and proactive approach to keeping people safe. One relative described being “extremely confident” that concerns would be listened to and addressed appropriately. Another told us, “The staff know my family member so well that they notice even the smallest changes. They act before problems develop and always keep us informed.”

The provider had created a strong safeguarding culture where people's safety, rights and wellbeing were promoted alongside their independence and choice. Staff received regular safeguarding training and demonstrated a thorough understanding of safeguarding responsibilities, reporting procedures and whistleblowing arrangements. One staff member told us, “It is my duty of care to ensure people are protected from harm, abuse or neglect.”

Staff demonstrated a proactive approach to safeguarding and risk management. They knew people exceptionally well and were able to identify subtle changes which may indicate increased risk. Staff took prompt action, working collaboratively with people, relatives and healthcare professionals to reduce risks before harm occurred. This helped people remain safe whilst maintaining their independence and quality of life.

Staff supported people to make informed decisions and promoted positive risk-taking. Rather than restricting people, staff worked in partnership with them and relevant professionals to identify safe ways for people to continue activities that were important to them.

Managers regularly reviewed safeguarding concerns, accidents and incidents to identify trends and opportunities for improvement. Learning was shared with staff and used to strengthen practice and prevent recurrence.

The provider responded appropriately to safeguarding concerns and worked effectively with relevant agencies when required. People, relatives and professionals consistently described a caring, vigilant and responsive culture where staff acted quickly to protect people from harm and ensure they felt safe, respected and valued.

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 were involved in decisions about managing risks and were supported to maintain as much independence and control as possible. Staff took a person-centred approach, balancing safety with individual choice and preferences. One person told us staff did not over-fuss and supported them to continue doing things independently, such as tidying their room and moving around the home. Another person said staff always asked before assisting them in their wheelchair, helping them maintain choice and control.

Risk assessments were used to identify and manage potential risks and were reviewed regularly or when people's needs changed. Staff monitored areas including skin integrity, nutrition, choking risks and falls, updating support plans to ensure people continued to receive safe and appropriate care. A social care professional told us, “Their approach to managing risk feels balanced and considered.

The provider supported positive risk-taking where this reflected people's wishes. For example, when 1 person wanted to shop independently, staff worked with them to identify and manage potential risks, enabling them to do so safely. Following falls, additional measures and safety equipment were introduced where needed to reduce risk while maintaining independence. One relative told us, “[Family member] has had 2 falls whilst being here and now has a camera beam to alert staff.”

The provider was fully aware of all potential risks in the care environment and controlled them well. They made sure equipment, facilities and technology supported the delivery of safe care.

People lived in a safe, clean and well-maintained environment where risks were identified, monitored and acted on promptly. During the inspection, the home was observed to be clean, uncluttered and free from environmental hazards. Communal areas, people's bedrooms and the garden were well maintained, and emergency exits were accessible.

The provider had effective systems in place to manage environmental risks and maintain safety. Fire safety arrangements included regular testing of equipment, fire drills and personal emergency evacuation plans (PEEPs) to ensure people could be safely supported in an emergency. Staff demonstrated a good understanding of fire safety procedures and their responsibilities for reporting and responding to maintenance concerns.

Staff described robust processes for maintaining a safe environment and managing equipment. Faulty equipment was removed from use immediately, clearly labelled and reported for repair or replacement. Daily and scheduled checks were carried out on the premises, fire safety systems and equipment to help ensure ongoing safety for people, visitors and staff.

Infection prevention and control practices were embedded throughout the service. Staff understood the safe use and storage of cleaning products, the use of personal protective equipment (PPE) and measures to prevent cross-contamination. Cleaning schedules, environmental audits and regular training supported the delivery of a clean and hygienic environment. One staff member told us, “I recently attended a COSHH refresher training course to ensure that my knowledge is up to date regarding policies, health and safety, and the safe handling and use of COSHH products.”

Records confirmed regular maintenance, servicing and safety checks were completed, supporting the provider's approach to maintaining a safe environment for people, visitors and staff.

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

People told us staff responded promptly when they needed support. One person told us, “They come quickly when I ask for help and help me.” Observations during the inspection demonstrated staff were visible throughout the home and responded to people in a timely manner.

Staffing arrangements supported the safe delivery of care and promoted continuity for people. Rotas showed planned staffing levels were maintained, and staff told us there were systems in place to cover absences when required. One staff member said, “If someone calls in sick, we are always there to cover the shifts.” Another told us, “I feel that management makes an effort to support the team and maintain safe staffing wherever possible.”

Staff received appropriate training, support and oversight to carry out their roles safely and effectively. Training records showed staff completed mandatory and role-specific training in areas including safeguarding, moving and handling, medication management, dementia care, dysphagia, end of life care and infection prevention and control. New staff completed a structured induction and probationary period, with additional support provided where required.

The provider followed safe recruitment practices to help ensure staff were suitable to work with people using the service. Required pre-employment checks, including Disclosure and Barring Service (DBS) checks, were completed before staff commenced employment.

The provider thoroughly assessed and managed the risk of infection. They always quickly detected and controlled the risk of it spreading and always shared concerns with appropriate agencies promptly.

People lived in a clean, hygienic and well-maintained environment. During the inspection, the home was visibly clean, and staff used personal protective equipment (PPE) appropriately. Relatives spoke positively about the environment, describing the home as “spotlessly clean” and “fresh and welcoming.”

The provider had effective systems in place to assess, monitor and manage infection prevention and control risks. Regular audits, environmental inspections and equipment cleaning checks were completed to identify and address areas for improvement. Records demonstrated good oversight and prompt action when issues were identified. One staff member told us, “Recently, I requested a new carpet-cleaning machine, and the management team provided one promptly. This enabled me to continue carrying out my duties effectively without unnecessary delay.”

Staff understood their responsibilities for maintaining high standards of cleanliness and preventing the spread of infection. Cleaning schedules, deep-cleaning programmes and housekeeping audits supported a consistent approach to infection prevention and control. Staff received appropriate training and had access to the equipment and resources required to carry out their roles safely and effectively.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People received their medicines safely and in a way that reflected their needs, preferences and choices. People told us they were involved in decisions about their medicines and had confidence in staff managing them appropriately. One person said, “All my medication is looked after by the staff. I know what I take and when. My tablets are always here for me.” Another person described receiving timely pain relief following surgery and told us staff had supported them well during their recovery.

The service had good medicines management arrangements, including the safe storage, administration and monitoring of medicines. A particular strength was the management of time-critical medicines, including Parkinson’s medication, where administration times were carefully followed to support people's health and wellbeing. People received regular medication reviews to help ensure their medicines remained appropriate and effective.

There were effective systems in place to monitor medicines safety. Medication audits showed clear management oversight, with actions identified and followed up where required. Staff responsible for administering medicines completed regular training and competency assessments to ensure they had the skills and knowledge to carry out the role safely.

Staff understood how to respond to medicines concerns and had a clear understanding of reporting and escalation procedures. They described seeking advice from healthcare professionals and management when required to ensure people received safe and appropriate care.

The registered manager was exploring the introduction of an electronic Medication Administration Record (eMAR) system to further strengthen medicines management processes. Although still in the planning stages, this demonstrated a commitment to continuous improvement and the ongoing development of safe systems.