Archived: Oak Tree Mews

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.

This is the first assessment for this care home under its newly registered provider. This key question has been rated Requires Improvement. This meant some aspects of the care home were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The care home was in breach of legal regulation in relation to the management of medicines, failure to submit a safeguarding referral, infection control concerns within the environment, and lack of appropriate premises for laundry segregation.

This service scored 44 (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. Leaders were working to embed a culture of openness and collaboration, but it was not consistent as robust learning processes were not always evident, and some instances of poor practice were repeated.

For example, in relation to medicines, we found serious concerns with records which were being repeated over time, meaning that audits were ineffective and staff were not reporting concerns. This demonstrated that lessons were not always learnt across the care home to continually identify and embed good practice.

At the time of our inspection, the service did not have a formal process to reflect on and share learning from events. Staff meetings were infrequent, and staff supervisions were not held. This meant there was inadequate opportunity for staff to be encouraged and supported to raise concerns about safety and ideas to improve care delivery.

However, there had been a serious choking incident in the care home in 2024 from which some lessons had been learnt, and the leadership team had implemented additional measures in response.

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 and support were planned and organised with people, together with partners and communities in ways which ensured continuity of safe care.

One healthcare professional who worked with the care home told us, “There is a strong sense residents are known well by the team, and their preferences, needs, and wellbeing are genuinely prioritised”. Another healthcare professional said, “The care and attention is excellent. The home recognises when a person living with dementia requires additional input and a referral is made”. Healthcare professionals who visited the care home during the time of our inspection due to a person’s deteriorating health also gave positive feedback about how staff handed over information.

There was some understanding by staff of safeguarding and how to take appropriate action, but safeguarding was not always given sufficient priority or applied consistently. The provider did not always share concerns quickly and appropriately.

During our inspection, we became aware of a person who had developed 2 pressure ulcers within 1 month of living at the care home. District Nurses were involved in this person’s care; however, the care home had not notified the local safeguarding team of this deterioration in the person’s skin condition. A safeguarding referral was made following our feedback during this inspection.

We also identified significant concerns with the administration of medicines in the care home, some of which had been identified by the registered manager in the medicines audit conducted 2 months before our visit. Despite identifying some concerns, the registered manager had not yet taken any action to mitigate the identified risks to people and therefore to safeguard them. Action was only taken to mitigate these risks following our inspection feedback. This meant people had not been sufficiently protected from harm in the care home.

People’s abilities to consent to care and treatment were not being consistently assessed, reviewed or monitored. Where assessments of mental capacity were being completed, these were found to be of poor quality. We could not be assured people’s individual rights were being upheld in respect of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards. DoLS’ are a set of checks to make sure that any care that limits a person's liberty is done in the least restrictive way and is in the person's 'best interests'.

We were informed by the registered manager that no one living in the care home would be able to leave without staff supervision. The care home was locked and there was a keypad for the second floor. The registered manager had submitted a DoLS application in relation to the locked doors for 14 out of 15 people living in the home.

The provider did not have effective systems to ensure DoLS approvals were monitored effectively. This meant people were at risk of unlawfully being deprived of their liberty. One person had previously had a DoLS in place, but this had not been renewed and the authorisation had lapsed. The registered manager told us it had been reapplied for but was now low priority to be reassessed. We saw information recorded about the individual had not been updated and incorrectly stated a DoLS was still current.

The provider did not give assurances staff and the leadership team had a good understanding of how to support people who lacked capacity. We saw 12 people had no mental capacity assessments completed, despite a DoLS application being submitted. There had been a failure to appropriately assess people’s capacity and follow the legal process before implementing decisions and restrictions. For the few people who did have capacity assessments, these were not time specific and had not been reviewed as part of reviews of the associated care plans. This meant there was no assurance the care home was reviewing each decision and restriction to ensure there had been no changes in people’s capacity.

Some of the decisions for which mental capacity assessments had been recorded were unnecessary, which evidenced further a lack of understanding of the Mental Capacity Act (2005) and how to safely uphold this for people.

Staff did not always adequately assess individual risks for people. People were not always appropriately involved in this assessment to ensure it was person centred.

The provider did not always work well with people to understand and safely manage risks. For example, a person’s falls risk assessment stated they were at high risk of falls due to their age and required a staff member to walk with them. The person’s daily care notes then described the person had walked to their bedroom independently at a later date, and this led to a fall causing bruising and a cut to their skin. Records detailed the person did not normally attempt to walk without staff accompaniment, however, in this case, they had, meaning the risk mitigation in place had not been sufficient as a preventative measure.

A healthcare professional who worked with the care home told us, “I have variable experience and knowledge of the staff […] I think the supervisors are generally able to identify risks, but my impression is there is a range of experience and skill set”.

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.
Some areas of the environment were found to be dated and tired in appearance. We also observed an area of mould in a communal bathroom, and some areas where paint was peeling from the walls.

Many of the people living at the care home had a diagnosis of dementia. During our inspection we found a lack of dementia friendly signage for directing people around the home, and all bedroom doors were painted white, which could make it difficult for a person living with dementia to find their bedroom independently.

However, equipment used in the care home appeared to be in good working order. The registered manager and provider told us they were generally able to arrange required maintenance tasks to be actioned in a timely manner by liaising with different contractors.

The care home had an emergency evacuation plan and appropriate fire contingency planning. Some of the fire paperwork however was still printed on paperwork displaying the previous provider’s name and branding making it outdated and potentially inaccurate. The registered manager informed us all staff members complete Fire Warden training; however, the training records showed 2 staff members had not yet completed this. Staff members appeared to know their role in responding to a fire. A staff member told us, “For every shift there is a trained fire marshal. There is a list by the fire panel with the names of the trained fire marshals to give the instructions throughout the procedure. We also have mandatory courses on the flourish learning app which must be completed yearly by all staff”.

The provider did not always make sure there were appropriately qualified, skilled and experienced staff on duty and 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.

At the time of the inspection, service leaders were not conducting staff supervisions. The registered manager had not yet conducted any staff supervisions since beginning in post 5 months prior. This meant there was a risk staff were not receiving adequate support to fulfil their roles. Staff members told us however they did feel supported by managers and leaders, and they appreciated the registered manager’s “open door policy”. One staff member said “the manager and deputy manager are always available, and weekend shifts are covered so 1 of them are available to offer support. They are very visible with in the care home and its nice the manager does not sit in the office, and interacts with staff, families and residents”. After feedback was provided during our inspection, the registered manager started to conduct staff supervisions and created a matrix to log these meetings.

There appeared to be enough staff on duty to meet people’s needs, and people living at the care home provided positive feedback. The provider did not have a system for monitoring call bell response times in the care home, which meant there was no robust way of assessing the length of time people waited to receive care. The manager told us they were awaiting training on how to effectively monitor the call bell system. The provider told us they sometimes manually check call bell response times in the care home but do not record this or check systematically. One person told us, “They [the staff] come on the buzzer very quickly. We need it [support] more at night, then they come fairly quickly”.

A Disclosure and Barring Service (DBS) check is a background search used to establish whether a person has a criminal record and is used by employers, amongst other pre-employment checks, to gain assurances that vulnerable people will be safe with staff members. During our inspection, we found that 1 staff member had been in post for 11 months and was working in direct contact with people without having had a DBS check completed. This staff member also had a significant gap in their career history which the care home had not followed up on during the recruitment process. This meant people were not appropriately safeguarded from the potential risk of harm from this person. The registered manager told us she had realised a DBS check was required for this staff member and had applied for one during the month before our inspection. However, no risk assessment or additional measures had been put in place to mitigate this identified risk to ensure people were safe.

Staff received training for their roles which mostly consisted of online training courses. At the time of our inspection, the registered manager did not have an overall training log to provide oversight of what training had been completed across the team or what training was outstanding. This meant the registered manager could not be assured staff were appropriately trained for their roles. Induction records for staff members were not available; therefore, it was unclear whether the service had an organised induction process to equip staff for their roles.

After our inspection, the registered manager created a training matrix to show training compliance across the team, however this showed many gaps and areas in which training was overdue. We were told the previous registered manager had been the trainer for moving and handling, and therefore since their departure in June 2025, there was no moving and handling trainer employed in the care home. The current registered manager explained she planned to become a trainer in this area; however, this had not yet been actioned. This put people at potential risk of harm from poor moving and handling practices. While we were on site, we observed an instance of poor moving and handling practice in a communal area which we reported to the registered manager. Due to the lack of effective oversight of training compliance, people were exposed to risk of harm.

The provider did not always adequately manage the risk of infection. The laundry room in the care home was very compact and did not allow for appropriate segregation of soiled and clean linens as clean items were being stored openly and very close to soiled items. This meant there was a risk bacteria could spread between items, putting people at risk of infection. During our inspection, the laundry room was found to be cluttered and unclean with an accumulation of dirt visible in many areas.

During our inspection, we also observed food being stored and served from kitchen trolleys which were not clean. For example, dried food was visibly stuck to the wheels of the trolley which put people at risk of being exposed to harmful bacteria and infection. We also observed an area of mould on the wall of a communal bathroom being used by people. When we raised this with the provider, they were not aware of the mould and therefore no action had been taken to resolve this. Following our feedback, the provider took action to address this.

During our inspection, we found there were at times odours of urine present in the environment. There was no schedule for the deep cleaning of bedrooms, and the registered manager informed us the cleaning checklists needed revising. We were informed there was not always a member of housekeeping staff on duty and on these days the duties were covered by other staff members, however records in the care home did not always evidence this. The environment otherwise appeared clean with a good visible standard of cleanliness, particularly in bedrooms.

We found significant concerns about the management of medicines at Oak Tree Mews. The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

We found a lack of oversight of the use of ‘homely remedy’ medications in the care home which meant people were exposed to risk of harm. Homely remedies are medicines which are available to buy over the counter and can therefore be given without a prescription, once appropriate safeguards are in place such as permission from a general practitioner (GP) or pharmacist.

Many records were extremely unclear and inconsistent and did not meet the expected standard of record keeping for medicines administration. We found the stock of homely remedy medicines was uncontrolled and items were being administered unsafely. For example, the last recorded stock count of paracetamol tablets in a log written by staff was 65 tablets, however on the day of inspection we counted 215 tablets in stock. The homely remedy stock also contained out of date medication, for example a topical ointment which had expired in 2023.

At the time of our inspection, there was no active approval from the GP for the use of homely remedies in the home which exposed people to risk. The GP’s, or another prescriber’s approval is required to ensure there are no unsafe interactions between a person’s prescribed medicines and a medicine which may be administered as a homely remedy. For example, some of the homely remedy medicines contained paracetamol and there were people in the home who were prescribed regular paracetamol, therefore it would be unsafe for them to be administered any additional medicine containing paracetamol as they were already prescribed the maximum safe, daily dosage. We reviewed the administration records, and due to the unclarity and inconsistencies within these records, we could not be assured that 1 person had not been administered an overdose of paracetamol tablets. This meant the person had potentially been exposed to harm due to the poor management of their medicines.

Some people were prescribed medicines which were to be administered 'as required', known as ‘PRN’ medicines, and these require additional protocols to inform staff of clear guidance to follow, including when to administer or how to review the effectiveness of these medicines. During our inspection, the staff member administering medicines to people was not aware of what a PRN protocol was or where this could be located. The registered manager showed us there was a folder of PRN protocols, however, many were missing, and many of those in place lacked essential details and had not been reviewed since 2023. For example, 1 person was prescribed a glyceryl trinitrate (GTN) spray for the relief of chest pain. The protocol for this had not been reviewed since 2024, was very brief and contained detail which contradicted the instructions on the prescription. This meant staff did not always have access to accurate and up to date information required for the safe administration of medicines, putting people at risk of receiving medicines inappropriately or ineffectively.