Oakdene Nursing 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 remained the same.

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.

The service was in breach of legal regulation in relation to safeguarding people from the risk of abuse and improper treatment, including consent to care and treatment.

This service scored 59 (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.

Vast improvements were made by the provider on how safety incidents were investigated and reported since our last inspection. People’s care plans and risk assessments were updated to reflect new learning, or ways to mitigate risk and promote safe, person-centred support. Openness and transparency about safety were actively encouraged. However, evidence showed the provider was not always open and transparent with people, their loved ones and staff when the incident occurred. We found that not all risks were dealt with and seen as an opportunity to put things right, learn and improve.

Incidents and accidents records were completed, reviewed and scrutinised. When identified, lessons were learned, discussed and communicated widely to support improvement duringregular staff meetings. However, evidence showed there was not always appropriate thorough review and investigation that involved all relevant staff, partner organisations and people who use the service when something went wrong. For example, we found a significant incident of choking that had not been investigated thoroughly that included staff involved and partner organisations. During our previous inspection in May 2024, we found an incident of similar status. This did not demonstrate that learning from the incident had been fully embedded and sustained in improved practice.

Staff felt encouraged and confident to raise concerns and report incidents and near misses. Staff felt supported by the management when they did so. Openness and transparency about safety were encouraged. Staff told us: “I follow a strict protocol: I would immediately assess the situation and ensure the resident's safety, notify the appropriate healthcare professionals, document accurately, and participate in a review to prevent future occurrences. We have accidents and incident reporting forms in place. Incidents which result in harm or have the potential to cause harm the manager will usually refer to the local safeguarding team and of which all safeguarding referrals are then sent to CQC. Near misses and incidents that do not cause any harm are recorded and fully investigated to identify root cause of the incident, lessons learnt and identify any training needs.” Other commented: “As a team we are reflecting on how the error happened and working together to prevent future mistakes, ensuring the highest standard of care.”

People and their relatives felt confident to raise concerns, felt they were listened to and believed actions would follow. Relatives told us: “If I have concerns, I am aware of whom to report to.There have been delays in action”, I am aware of who I should report any issues to. I have always received a prompt and satisfactory response from staff at the home” and “I would report any concerns to [staff names]. They would be listened to. When I requested a grab-bar to be installed in [my loved one’s] room, this was implemented.”

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.

Improvements were made to ensure people’s involvement and establish better working relationships with healthcare partners to ensure safe systems and continuity of care. However, evidence still showed shortfalls in communication and partnership working and further improvements were needed. We received mainly positive feedback from people and their relatives about maintaining continuity of care and their involvement in creating and reviewing people’s care records. One relative told us: “I like being involved; however, I feel often there are changes to medication or there have been doctor's visits I have not been informed of. I get texts from the GP Surgery that [my loved one] has a visit and I then have to enquire with the home as to what this is about. Information (depending on senior staff) is not proactive which leads me to 'nagging' emails. Recently there have been no response to queries. I would like to think I am a regular visitor so there can be no excuse that I am a remote family member.” Other relatives commented: “The staff do get in touch if my mum has seen a doctor etc, so I’m kept in the loop.”

Staff told us they encouraged involvement of people’s relatives in care planning: “We ensure communication with families and friends by updating them on each resident's daily. We review care plans and risk assessments for every resident of the day, we call the family we discuss with them if any changes if there are no changes we still call them give an update find out if they are happy with the care provided and if there's anything they would like us to do.”

However, we received mixed feedback from health and social care professionals. Comments included: “The regular staff are ok to work with, no concern. The only frustrating thing is the phone system. When GP keeps trying to call and there's no reply. When discussing a case with agency staff, they don’t know full history. When we asked them what is the issues, including when our paramedic or our health care assistant visit a care home, they are struggling to find someone to go with them to show where is the patient and also what are the issues” and “Staff do not appear to know the residents very well, for example, a quote from a member of staff to a colleague recently “I’m agency, I don’t know the patient”. When a nurse is visiting a patient whom we do not know (e.g. new referral), carers have a responsibility to know some information about residents in their care. Carers should be receiving hand-over from colleagues at shift change. Bank/agency staff should not be accompanying nurses to visit residents. It should be a more experienced member of staff. A colleague has informed me they were taken to the wrong resident by a carer.” Other professional commented: “I have not had any negative experiences at the nursing home. Staff have always been helpful and none of the residents I have visited ever expressed concerns or made me question the quality of their care.”

Pre-assessment paperwork was always completed involving people, relatives and partners prior to people moving into the service and shared with staff. Assessments of needs were communicated with staff when people moved into the service or returned from a hospital stay via daily handovers and daily meetings. Compatibility and whether the service was able to meet people’s needs was always considered during pre-assessment process and following change in needs. Appropriate referrals to partners were made in a timely and effective way.

Evidence showed processes of safety and continuity of care through a collaborative, joined-up approach to safety were not always consistently applied by all staff, fully embedded in the service and always involved people in their care along with staff and other partners. Appropriate referrals were made to relevant healthcare partners. However, communication with healthcare partners was not always effective and their guidance and instructions after the referral and assessment visit not always followed by staff. When healthcare professionals visited people, staff were not always readily available or able to provide relevant information relating to people’s conditions. Communication with healthcare partners was not always effective and their guidance and instructions after the referral and assessment visit not always followed by staff. We reviewed an incident when staff failed to communicate with healthcare professional which resulted in a delay in person receiving treatment for swelling and redness to their leg and suspected blood clot.

The provider did not always 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 always share concerns quickly and appropriately.

The provider had safeguarding policies and procedures in place, but they were not consistently followed by staff. The provider was not always fully engaged with local safeguarding systems and had not always made referrals to the local safeguarding team following incidents where people had been at risk of abuse. This meant external scrutiny was not possible to ensure people were safeguarded from abuse. During the inspection we found incidents of harm which were not identified, followed up or raised with the local authority. The manager at the time were aware of these incidents, however had not shared these concerns appropriately with local safeguarding systems. The provider responded promptly to address shortfalls identified during and after the inspection. The service sent us evidence which demonstrated they fully engaged with local authority, arranged additional staff training and intended to update care plans and risk assessments for people living at the home. We were not able to review actions taken or how sustainable these improvements were.

Staff had received safeguarding training. However, 7 staff members were not up to date with safeguarding training; with overall completion rate 80% when we visited. Despite this, staff were able to tell us how to recognise the signs and symptoms of abuse and who they would report concerns to both internally and externally. Staff told us: “If I had any concerns I would report it to the management. If it was abuse and the home was not dealing with it then I would contact safeguarding” and “If I were concerned that someone might be experiencing abuse, I would follow the correct safeguarding procedures to ensure their safety. The steps I would take include: inform deputy manager, or the manager, follow the Home’s Safeguarding Policy, report to the Safeguarding Lead, Local Safeguarding Authority, Care Quality Commission and the Police (if urgent).”

However, people and their relatives felt the service provided by Oakdene Nursing Home was safe. Comments included: “[My loved one] is safe, well-fed, relatively healthy given [their] condition and generally in good spirits. They are healthier and happier at Oakdene than [they] were living at home” and “I feel that the care my [loved one] receives at Oakdene is safe.” While the people we spoke to expressed that they generally felt safe with their care as described by people, our assessment found elements of care did not meet the expected standards.

The provider had processes in place to ensure people were involved in decisions about their care so that their human and legal rights were upheld, however they were not always effective.Staff had received training in The Mental Capacity Act (MCA) with completion rate 98% when we visited. However, staff not always demonstrated good working knowledge of the key requirements of the MCA on how to uphold people’s rights to make sure they have maximum choice and control over their lives, and how to support them in the least restrictive way possible. Fo example, we found 1 person was prescribed medication to be administered when required at times of distress. We found that medication had been administered to them as regular medication each evening without any justification in daily notes, which stated they appeared calm and settled. We raised this with the manager, and they took immediate action to rectify this.

People were not always supported to have maximum choice and control of their lives and staff were inconsistent in supporting them in the least restrictive way possible and in their best interests; the policies and systems in the service contributed to this practice. People did not always have the necessary assessments in place to ensure their rights had been fully respected under the MCA. Staff had not always considered whether people have capacity to make particular decisions whenever this was necessary and not always followed principles of a best interest process in accordance with legal requirements, when a person lacked capacity to consent to the arrangements for their care and treatment. For example, we found no evidence of mental capacity assessments or subsequent best interest decisions completed for the use of restrictive practices like chair alarm, low bed, pressure mats or chemical restraint completed for all 7 residents living in dementia environment. We discussed this with the management who immediately commenced a review of paperwork held for people. We will assess these changes at the next inspection.

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 and their relatives felt involved in managing risks and risk assessments were person-centred, proportionate and reviewed regularly. Most relatives including people’s legal representatives, told us they were recently involved in creating and reviewing people’s care plans. Comments included: “We have had a care plan review and my [loved one] is no longer able to get involved” and “I have been involved in my [loved one’s] care plan review in recent months.”

Staff told us they were given enough information about people’s risks and how to keep people safe when providing their care, for example how to support people with complex behaviour, swallowing difficulties or diabetes. Comments included: “Having enough information about people’s risks is essential to providing safe and effective care. While some information is provided, I believe there is always room for improvement in ensuring that staff receive clear and up-to-date guidance on managing complex behaviours, swallowing difficulties, diabetes, and other health conditions. I always make sure to follow care plans, ask for clarification if needed, and remain observant to keep people safe while supporting their individual needs” and “We are given enough information about people’s risks and how to keep them safe. This depends on the effectiveness of communication, documentation, and training within the home. We have access to people care plans and risk assessments, handovers, training and guidance on managing risks such as falls, pressure sores or behavioural challenges. We have open communication between staff, senior carers and management to raise and discuss concerns.”

People’s risks were assessed before they started to use the service and added to as needed. Risk assessments were created and maintained within the provider paper-based care planning system. Assessments were updated regularly and as things changed. Relevant health and safety concerns were included in people’s care plans. The provider identified risks to people’s health, safety and welfare for example, risks associated with people’s mobility, swallowing difficulties and malnutrition. These were always effective and followed best practice guidance.

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.

The provider’s approach to assessing and managing environmental risks was inconsistent. Arrangements were put in place to monitor the safety and upkeep of the premises, bringing in professionally qualified people to complete the necessary environmental and equipment checks. Those arrangements were not always robust and effective and did not identify shortfalls found at this inspection. The safety of the premises, communal and personal spaces (such as bedrooms), and the living environment were not always checked and managed to support people to stay safe. For example, we found that some window restrictors in bedrooms on the first floor in the Oakdene Lodge were not compliant with British Standards and legal specification, which requires restrictors should only be able to be disengaged using a special tool or key. We raised this with the manager, and they told us they recently identified this issue and would be replacing window restrictors. People had moved to alternative bedrooms until it would be safe to return. We also found that hot and cold water temperature checks to ensure water services operated at temperatures to prevent legionella bacteria growth were ineffective and not applied consistently to the whole home.

The provider did not have effective fire safety procedures in place. For example, a fire risk assessment was completed in March 2024 had all required actions marked as completed. However, there was a repeated action still outstanding in the new fire risk assessment completed in March 2025 - smoke detection had not been provided in the roof void outside one of the bedrooms in Oakdene Lodge. We also found inconsistencies in people’s records on how to support them in a case of fire. We found that personal emergency evacuation plans for 2 people contained conflicting information and guidance on how to support them in case of fire than resident evacuation register document kept in an emergency grab bag. This meant people were at increased risk of harm from fire. We raised concerns with the manager and they took immediate action to rectify all shortfalls. We will assess safety of new arrangements at the next inspection.

There was no evidence that night time fire drills or evacuation exercises were conducted. There had been a recent change to the head of maintenance and frequent changes to the management over last 6 months. The arrangements for the availability, integrity of data, records and data management systems in relation to the environmental safety had not always been effective. Requested documentation relating to safety of the premises was not always availableat the time of inspection. Some documents were requested and received electronically after our site visit. The manager told us they were putting new systems in place following recent change to the head of maintenance. We will assess safety of new systems at the next inspection.

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.

Appropriate Disclosure and Barring Service (DBS) checks and other recruitment checks were carried out as standard practice. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. However, the provider’s recruitment systems did not demonstrate that all staff, including agency staff and volunteers, were suitably experienced, competent and able to carry out their role. For example, we reviewed recruitment file of 3 staff members and found 1 member of staff was working for a period of nearly 7 months without appropriate DBS checks carried out. This meant recruitment systems were not always effective to ensure that the right staff were recruited to support people to stay safe. We discussed this with the manager, and they commenced a full review of all staff files on site to ensure that no further information was missing. The provider reviewed their recruitment policy to ensure safer recruitment processes. We will review safety of the new systems at the next inspection.

The service regularly reviewed staffing levels using dependency tool which calculated the number of staff needed. We were not assured people were always supported by sufficient numbers of staff to meet their needs.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

During our SOFI, we observed people appeared calm and relaxed while supported by staff. People appeared to be treated well by staff who knew them well. However, we observed staffing levels were not always appropriate to make sure people receive consistently safe, good quality care that meets their needs. During lunchtime observation in dementia environment, we observed person getting increasingly distressed which impacted on some others not eating their lunch and walking away removing themselves from the situation. One member of staff was serving food and another was supporting one person with eating on one-to-one basis. A distressed person was not given all the support they needed or removed from the situation. We were told that another staff member was supporting bed bound resident with their lunch at the time.We received mainly negative feedback from people and their relatives about staffing levels and skill mix. Relatives told us: “We often can't locate a staff member to answer a query”, “I do not feel there are enough staff” and “You can wait for ages before anyone comes as they are busy with other residents so I would say it’s the main problem.” Other relatives commented on recent improvement in staffing: “They have moved [persons’ name] to a part of the home where there are more staff which is great” and “There seem to be more staff, who are more present amongst the residents.”

Relatives commented on high turnover of staff and managers. Comments included: “Due to the turnover of staff I do not feel they know my [loved one] as well as they used to. Their health deteriorated and I feel that they are [they] are the person in bed whose basic needs are met.” and “There have been recent improvements, staff have been to other homes to learn from experienced staff, staff from other homes have also been present at Oakdene to advise. Interactions with patients seem to have improved.”

Most staff told us there were not enough staff working at Oakdene Nursing Home to ensure people’s needs are met. Staff told us: “I wish the number of clinical staff will be increased. The workload is too much for only 3 staff at night looking at all the work involved”, “We desperately need more care staff. Agency usage is unbelievably high” and “I think there are not enough care staff and for that reason carers get exhausted. Residents’ needs are not fully met even though they are well taken care of.” Staff told us they felt staffing levels decreased recently in dementia environment were unsafe and complained to the provider. Staffing levels were increasedeventually after 2 weeks prior to inspection and staff expressed their concern staffing would be decreased again after the inspection.

Professionals told us: “The major thing is when a GP tried to reach Acorn or Oakdene, no one is answering, the GP has tried to do this many times. Solution is to employ more staff so that then can answer phones when GP or nurse or other health professional try to reach, also employ more regular staff (not agency staff) to be more familiar with patient and to take extra care when giving medication” and “Carers will usually accompany our team members to a resident’s room, however on occasion, when the are visiting a resident they know, the carer will step out of the room. Sometimes, when we have finished, we are unable to find any carers to hand over the care we have given. Staff do not appear to know the residents very well, for example, a quote from a member of staff to a colleague recently: I’m agency, I don’t know the patient.”

However, staff received training appropriate and relevant to their role, and service, with their competency assessed. Training was refreshed at regular intervals to maintain knowledge and skills in line with best practice. Staff did not always feel supported and did not receive regular supervisions as per provider’s policy.

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.

Infection prevention and control was at the core of the service and staff had received training with regular updates. Cleaning records demonstrated what was being cleaned. Managers at the service had oversight of infection prevention and control (IPC) and carried out regular audits and checks of all aspects of infection control. The provider’s IPC policy was up to date. Infection prevention and control procedures were robust, in line with the providers policy.

People were protected as much as possible from the risk of infection because premises and equipment are kept clean and hygienic. They were supported to maintain their own personal hygiene in line with their needs and preferences.

Staff had completed training in IPC, the completion rate was at 85% when we visited. Staff were trained and understood their role and responsibilities for maintaining high standards of cleanliness and hygiene in the premises and their own personal hygiene, including hand hygiene. Housekeeping staff told us they conducted daily cleaning schedules and checks to ensure processes were being followed and all areas were being cleaned. During the site visit we saw cleaning taking place. We observed the service was clean and free from odours. Personal Protective Equipment (PPE) like disposable gloves and aprons were available throughout the service, and we observed staff using PPE safely and appropriately. Compliance with the infection control policy was observed during daily IPC monitoring checks conducted by the manager at daily walkarounds, where staff demonstrated how to work in a safe and clean way.

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.

Staff managed medicines consistently and safely. Medicines were ordered, stored at the correct temperature and disposed of securely. Controlled drugs were stored, recorded, administered and disposed of safely. There was an effective oversight of their handling in line with current legislation and guidance.Medicines records showed that they were given as prescribed for people. Personalised protocols were in place for all medicines prescribed ‘when required.’ People wishes and preferences about how they like taking their medicines were clearly recorded in their care plans. We observed staff giving medicines safely and in a kind and caring way, taking time with people, and asking if any ‘when required’ medicines were required. We observed people’s individual preferences for how they liked to take their medicines were respected by staff. Medicines incidents or errors were reported and investigated.

People and their relatives felt they received their medicines in a safe way. Comments included: “I am happy with the administration of medication to my [loved one]. I recently received a phone call from one of the visiting members of staff to say that [their] meds were being reviewed and would be changed to liquid where possible as my [loved one] sometimes refuses and struggles to take their meds” and “I feel my [loved one] is well supported with their medication by staff at Oakdene. I witness the administration of the meds and we review this often.”

Staff told us they felt well supported regarding medicines management, and that they felt that the systems in place vastly improved. Staff told us: “We worked very hard with the support from the local pharmacist who visited to help us improve medicines management in the home”. They told us they had training, and competency checks to make sure they gave medicines safely. They were able to describe how medicines errors or incidents were recorded and followed up, and they knew the procedure to follow if people refused to take their prescribed medication. Staff told us: “In my role, I am responsible for medication management. Should I discover a medication error, I follow a strict protocol: I would immediately assess the situation and ensure the resident's safety, notify the appropriate healthcare professionals, document the error accurately, and participate in a review to prevent future occurrences” and “I administer medication to the resident as prescribed be the GP. If I discover any medication error, I would follow the protocol by completing an incident/accident form, inform the senior management who would deal with the safeguarding the incident, I would inform GP, family/NOK and get professional/medical advice on what to do from the GP regarding the medication error, also update the documentation i.e. daily note and family communication records.”

Professionals expressed positive feedback in regard to medicines management: “I have visited Oakdene and met up with [staff name] and I can honestly say that I found the home to be friendly warm relaxed the residents were happy and smiling. [Staff name] was very professional and approachable at the time of meeting we discussed how the whole prescription journey works how the interim service works and I felt [they] were more than happy to work together for the patients. I feel people are well supported with their medication. Communication is good from the home although they could be a little better at sending over emails when requesting interims medication. I feel that they are one of our better run homes in terms that they are very well organised, and the communication is good (room for improvement) there is very rarely a problem if we do encounter a problem, it is swiftly dealt with.”