Oak Tree Lodge

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. Staff told us they reported accidents and incidents using the electronic care planning system. One staff member said, “I report the accident onto [electronic care planning system]. We are prompted a few hours later to say what we have learned, and we will do in the future to prevent it from happening again.” Learning was shared using a handover system and in regular staff meetings.

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. Staff told us, “Before someone moves in, we go to meet them and complete an initial assessment with them. We make sure we can meet their needs.”

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.

Staff knew how to protect people from abuse and who they would report any concerns to both internally and externally. One staff member said, “I would report any concerns to the seniors or managers and if I felt I needed to, there is the local safeguarding number.” Where people lacked capacity to make their own decisions regarding where they wanted to live, we found appropriate legal authorisations for Deprivation of Liberty Safeguards (DoLS) were in place.

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 had assessed people for risks relating to their health, safety and welfare. Staff supported people to manage risks whilst maintaining their independence by promoting positive risk taking. For example, people were assessed for risks relating to falls, choking, and to their skin integrity. When risks had been identified, staff followed actions to keep people safe, such as providing specialist equipment to protect people from skin damage.Risk assessments were regularly reviewed and updated when people’s care needs changed. Staff we spoke with understood the risks to people and the actions they needed to take to keep people safe.

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 building and equipment used to meet people’s needs were regularly serviced and well maintained.

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. We observed there to be enough staff to meet people’s needs. People and their relatives mostly told us there was enough staff to meet their care needs. One staff member said, “If we find we need more staff we can speak to [registered manager] and they will organise someone extra for a few hours.” However, some staff felt they did not always have enough time to spend 1 to 1 time with people after their personal care was completed. One staff member said, “We don’t take proper breaks as there are not enough staff to support residents who need 2 to 1 support and answer the bells. It’s particularly concerning in the afternoon and at night.” We discussed this with the registered manager who said, “We use a dependency chart that shows during the day we are actually overstaffed with the managers and wellbeing coordinator. At the weekend we put on an extra member of staff. We have an on-call system in place and in the past have put on twilight shifts as needed to support residents who need extra support.” Safe recruitment practices had been followed to ensure staff were of good character and had the right skills to meet people’s needs. A full induction was provided, and staff training was regularly updated to ensure people’s needs were always met. Staff received regular reviews about their performance that was supportive. One staff member said, “When I started, I spent the first couple of weeks shadowing others and reading people’s care plans, getting to know them before starting to care for them on my own.” Another staff member said, “The training is good, we get some online and some face to face, the training applies to my role.”

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 was clean and free from the spread of infection throughout. Robust cleaning schedules were in place and regularly reviewed by staff and the management team. One relative said, “Whenever we have come, it always smells clean.”

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.Medicines were given safely and people received them as prescribed for them. When people were prescribed patches, the sites of application were recorded and rotated appropriately. However, the removal of previous patches was not always recorded. We discussed this with the registered manager who took immediate action to ensure staff recorded when patches were removed to mitigate the risk of an overdose. Staff we spoke with said that they felt well supported with medicines, and systems worked well. They were knowledgeable about people and their medicines. People’s preferences were considered. When medicines were prescribed to be taken ‘when required’ there was information in place to guide staff when these might need to be given. Risk assessments were in place for high-risk medicines and regularly reviewed. Medicines were stored safely and there were appropriate arrangements for disposal, and for controlled drugs. There was suitable temperature monitoring being carried out.Staff training and competency checks were in place and documented. There were regular medicines audits and areas for improvement were identified and actions put in place.