Oakwood Acquired Brain Injury Rehabilitation Service

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 changed to 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 a legal regulation in relation to the way people’s medicines were managed.

This service scored 50 (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 recognise concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

We found some shortfalls in how lessons were learnt. For example, we noted an incident where one person had brakes on their bed which were faulty but it was not evident that this was addressed in a timely way or all action to mitigate the risk has been taken, and this person had a fall from their bed. We noted shortfalls in how people’s care needs were reviewed, with limited evidence that relevant risk assessments were reviewed following a change in need or incident, for example following a fall or development of a wound.

Handover records were used to update staff on any changes to people’s needs but this was inconsistent and did not ensure all staff were updated following any periods away from work. Records held at the service in relation to incidents were poorly organised at the time of the assessment and we were not certain all the relevant information was available to staff within the provider’s governance systems.

The provider had a lessons learnt log and there was evidence of oversight of clinical issues and near misses. However, at the time of our visit some of these issues were not yet resolved. The changes at management and team leader level meant that many processes had not yet been embedded. A recent system of meetings during the day for key staff had been implemented to ensure key information was shared and actioned.

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.

We received mixed feedback about how people were supported to access other services. Some relatives commented that people had missed outpatient and other scheduled appointments due to a lack of an organised and coordinated approach. One relative commented, “[Family member] has scheduled appointments, which they missed. There was no money for a taxi to take them was the excuse.”

People had detailed plans for intervention to improve people’s independence and skills for daily living which had been developed by the therapy team. It was not always evident that these care plans were followed and we noted opportunities to promote independence through cooking meals, laundry, cleaning and shopping were not being fully utilised. One relative commented, “You are led to believe they follow up interventions, but they don’t.”

We received positive feedback from some external professionals, with one professional telling us, “Communication via telephone, face to face, and via email with case manager, management and carers is always spot on. They are responsive, approachable and easily contactable if ever needed. If the client has had any illness or upcoming hospital appointments and cannot make the appointment for whatever reason they always let us know with plenty of notice.”

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 or respond to concerns quickly and appropriately.

People had mixed views about the safety of the service. Most people felt safe, although concerns over the security of areas of the home were raised with the provider following feedback from people and families. People and relatives said that how safe people felt would depend on the staff on shift. One relative commented, “[Family member] is more safe with some than others.”

We noted there had been some shortfalls in ensuring timely action was taken in response to environmental issues. For example, one person had experienced a fall whilst waiting for the brake on their bed to be replaced. There had not been any recent fire drills in the organisation and, although this had been identified as an area of shortfall, the required action had not been taken in a timely way and emergency evacuation plans had not been kept up to date within the emergency bag. However, there were also some very positive examples of good practice, where staff strongly advocated for people when they were unwell, and ensured they got the right support and treatment.

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 safe, supportive and enabled people to do the things that mattered to them.

The provider used a range of risk assessments and care plans to assess and mitigate risk. However, these were not consistently subject to review to ensure they remained up to date and relevant. There was limited evidence that people or their families had been involved in recent discussions on these matters.

There was limited evidence to demonstrate that care was consistently delivered in line with care plans to mitigate risk, such as the provisions of regular oral care, promoting healthy eating or following therapy interventions. We noted some staff worked hard to support people and manage and mitigate risk where possible which included advocating for people to access services they needed.

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.

Many areas of the home were in need of redecorating or updating. We found many areas where flooring or furniture were damaged and difficult to clean, with areas of the ceilings and walls damaged in some rooms. The outside space was secure but posed a risk to people due to uneven surfaces, and areas of the garden were used to store broken or damaged equipment including beds parts and an old fridge. People had their own bedroom and bathroom, with some people also having a kitchen and living area which was personalised and homely. However, the communal lounge, dining area and kitchen were in need of updating to make them pleasant and homely areas for people to spend time in. People had their own space for storage of food in the kitchen but there were no clear systems to ensure food was stored at the correct temperature, or that adapted equipment to promote people’s independence in preparing meals was in place. One relative commented, “The kitchen is not great, there’s no chef, agency staff try to cook [but they do not know what they are doing]. There’s no equipment, no knowledge of how to cook.”

A maintenance person was in place but it was not evidence that they had sufficient time to do all that was expected of them. The systems in place at the service did not allow the maintenance person to have oversight of all areas of maintenance within the service, and we found some recommendations made from external checks had not been followed up. Immediate action was taken to address this. People spoke highly of the maintenance person and found them to be very helpful and responsive to requests for repairs. Systems were in place which ensured appropriate checks of equipment and utilities were being completed. For example, firefighting equipment and alarms were checked on a regular basis by the maintenance person.

During our site visit we found large furniture had not always been attached to the wall appropriately and this was quickly addressed. We also noted a mass outbreak of flying ants on the first day but this had been mainly resolved by the second day of inspection.

There was a system for checks of the environment, but this was not reflecting where areas for improvement were needed. However, there was a suitable action plan to address many of the environmental issues.

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.

People and families did not always feel there were sufficient staff to meet their needs. One relative commented, “[Family member] needs to be transferred by two people. One [member of staff] comes and has to call for another. Sometimes this has been problematic, [family member] had to wait 20 minutes once and they are struggling with incontinence.”

Staff told us the use of use of agency staff was improving but staff were often very busy. At the time of our visit, it was evident that insufficient hours were being allocated to maintenance and the environment.

Recruitment processes were not always suitable and robust to ensure safe recruitment with appropriate checks from previous employers. There were limited records to evidence that staff received a full induction, had assessments of their competency to deliver care, or were receiving ongoing supervision or appraisals. Improvements were needed to ensure staff were fully compliant with the training needed to do their role, and we noted some training in key areas of care delivery had not been completed. The interim manager and deputy were in the process of addressing these matters. Staff generally told us they had a good induction process before working independently with people.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

There were several areas of the home where the damage to the environment made good infection control practices difficult. Systems were in place for checks of infection prevention and control but not all of these had been completed recently or reflected an up to date view of the service.

Staff had mostly completed training in infection prevention and control, and there was access to personal protective equipment. However, there was limited evidence of competency assessments or spot checks in relation to infection prevention and control at the time of our visit. Cleaning and checks of the communal kitchen were not always being completed, including opening and closing of the kitchen and where fridges had thermometers, it was not clear these were being checked as several of these required batteries.

People appeared clean and well cared for and told us they had regular support with personal hygiene and oral care.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Medicines were stored securely.

Not all staff had completed training for their role in medicines administration, although all had their competency assessed.

Stock balances of medicines matched those expected and stock checks including controlled drugs were done twice daily. However, we found that temperature monitoring of areas used to store medicines was not carried out daily and when temperatures had gone out of the recommended range there was no action documented to ensure medicines were stored safely.

For medicines that were administered ‘when required’ (PRN) there were not always instructions in place for staff to administer these medicines.

Care plans for chronic conditions were not always in place, however when they were they contained information that ensured that staff would be able to manage people’s medicines.

We found for one person who struggled with accepting medicines due to their confusion, staff had put an intervention in place that supported the person to make decisions about their medicines. People’s records included person-centred information on how they liked to take their medicines.

Medication administration records for preparations such as creams and mouthwash were not always completed accurately, so we could not be assured that people were having them administered correctly.

The service was carrying out audits of medicines and although they had picked up on some of the issues found during the inspection there had not been sufficient processes put into place to ensure issues had been rectified.