The Oaks

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 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 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. There were systems in place to learn from safety events, to understand why a person had become distressed or an incident had occurred. Staff worked collaboratively, with the person or their representative, other professionals and the providers positive behaviour support (PBS) team to understand why someone was distressed and the best way to support them to keep them safe and happy. They explored what could be changed or put in place to prevent further occurrences and lessons were learned to continually show and embed good practice. People and staff received debrief sessions following any incidents. We received relatively good feedback from relatives we spoke with. One relative said, “We have no problems raising concerns and we are well heard. Staff definitely do their best but situations at times are difficult.”

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. Care plans showed people were supported to access services relevant to them such as referrals to occupational therapists for new equipment, to the acute trust for dietician support and sensory assessments. Processes were in place to support transitions between services. For example, when people needed to go to hospital.

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. All people we spoke with told us they felt safe. One person said, “I love it (here),” and another person said, “A member of staff makes my day good.” Relatives spoken with also confirmed they felt their family members were safe. One relative told us, “[Person’s name] loves it, doesn’t like change and would get upset if routines altered and [person] gets on well with the carers.” Staff understood how to recognise signs of abuse and knew how to report any concerns. Records showed safeguarding incidents had been managed appropriately and referred to the right agencies such as the local authority and notified to CQC. There was a commitment to minimising the use of restrictive interventions. Appropriate processes were followed where it was deemed necessary to use restrictive physical intervention to protect the person or others. This had been agreed by professionals in the persons best interest and used as a last resort. Staff completed documentation when a restrictive intervention was used. Where people were being deprived of their liberty, applications had been sent to the local authority for authorisation. The registered manager had a tracker in place which detailed authorisation and expiry dates. We discussed and suggested the provider consider developing there DoLS tracker further by adding more detail such as any conditions and date to reapply.

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. Staff knew people’s risk assessments. They told us how they supported people who become anxious or distressed to lessen the risk to themselves and others. For example, a person had been involved in an incident in a vehicle. Their original risk assessment and measures in place had not been effective therefore, a multi-disciplinary meeting was held with the person, their family and relevant external professionals to discuss reasonable and proportionate restrictions to ensure the safety of the person, support staff and members of the public. Following this a referral was made for occupational therapist oversight to purchase new equipment to use when travelling in vehicles to prevent a similar incident from happening again. The registered manager and assistant manager provided many examples of how staff supported people to engage in positive risk taking.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.Records showed safety checks were carried out around the home and staff told us if anything required attention such as any broken items they were immediately replaced. For example, one staff told us the TV had broken and was replaced with a new one the next day. We saw on January 2025 health and safety audit the tumble dryer was tripping the electrics. Following a visit from an electrician on inspection it was identified the plug socket had been scorched and damaged. This was immediately resolved by changing the plug and checking over appliances to ensure everything was safe and working as required.We identified one communal toilet had some exposed piping under the sink. The registered manager assured us they would address this without delay. People were supported to be safe within the environment. Where people did not have capacity to understand risks appropriate restrictions were in place, such as a key code on the door to access the kitchen. Personal emergency evacuation plans were in place for people which included information about the person, physical considerations, neurological considerations and general medical conditions which may affecttheir evacuation in the event of a fire and their awareness of evacuation and procedures.

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. People told us there were enough staff. One person said, “all (staff) are nice, and they are our friends.” Relatives also felt there was enough staff. However, one relative said, “Definitely appears to be (enough staff) but less when out of the home. They need more drivers so they can go out more often.” And another relative said, “Had a few problems in the past. Staff change often and although they (people using the service) get used to it, it can be a bit confusing.” Staff had received relevant training to carry out their roles effectively. This included training in areas such as communication, learning disabilities, autism, positive behaviour support and the care certificate. The Care Certificate is an agreed set of standards that define the knowledge, skills and behaviours expected of specific job roles in the health and social care sectors. It is made up of the 15 minimum standards that should form part of a robust induction programme. Staff also received additional training to meet people’s needs such as diabetes, epilepsy and Parkinson’s training. People felt staff were well trained and knew what they were doing. One person told us, “Staff are very well trained,” and another person said, “Especially my keyworker.” Relatives spoke well of staff. Comments included, “Keyworker very well trained and management are very approachable,” and “On the whole excellent staff.” However, one relative did share it didn’t always look good when staff were using mobile phones for logging and accessing information as you can’t tell if its work or just chatting but went on to say, “but they are a good bunch and work hard.” Staff accessed mobile phone devices to log care notes and to access information. Staff confirmed they received supervisions and told us they did not have to wait for their planned supervision if they required one sooner. Despite this the supervision log showed there had been a long period of time where some staff did not have a recorded date of a supervision being held. The registered manager told us they had many conversations with staff which were not planned supervisions and moving forward they will ensure all these conversations are logged to show staff are able to speak with the managers whenever they need to, and managers are listening to staff. Where unexpected staff absences occurred such as illness, there was a system in place to cover any staff shortages. This helped reduce any need for agency staff and meant people were supported by staff who knew them well. The provider had robust systems in place to ensure staff were recruited safely. This included checking their identity, their eligibility to work in the UK, obtaining at least two references and Disclosure and Barring Service (DBS) checks. The DBS checks helps employers make safer recruitment decisions and prevent unsuitable people from working with vulnerable people.

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 home looked clean. There were some areas which needed cosmetic improvement, for example, hand banisters and some skirting boards which were chipped. The provider had plans in place for routine painting, flooring, and replacement of furniture. The home had recently had a food hygiene inspection and was rated 5 star. This meant food hygiene standards were very good and fully comply with the law.

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. We observed staff administering medicines at lunchtime. The staff member followed the guidance within people’s care plans in relation to choices such as preferred route they take their medicines. The staff member spoke with the person about their medicines and gained their consent before administering. Medicines were safely stored in individual’s bedrooms and appropriate checks such as medicine stock and temperature checks were being carried out. Three people told us how they were supported with their medicines and said, “no mistakes were made.” One person told us how they had cream applied for a sore toe after a bath. All relatives spoken with said they had no concerns in relation to their loved one’s medicines. One relative said, “Any medication problems they (staff) will let us know straight away.” The service ensured people's behaviour was not controlled by excessive and inappropriate use of medicines. Medicine reviews were undertaken by the Psychiatrist who ensured the principles of STOMP (stopping over-medication of people with a learning disability, autism or both) were followed. Guidance was sought and followed from other health and social care professionals to achieve this. When people were out of the service such as visiting family staff ensured their medicines were properly signed in and out to maintain clear and accurate records. We shared with the registered manager to consider family members signing the documentation to confirm receipt of the medicines received. There were regular audits of people’s medicines. Any medicines incidents were appropriately reported and investigated, so measures could be put in place to prevent a recurrence and learning could be shared.