Oak Tree Mews

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• 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 changed to Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, the way people’s medicines were managed, premises and equipment and staffing.

The provider was previously in breach of the legal regulations in relation to people’s safe care and treatment, the way people’s medicines were managed, safely, consent to care and premises and equipment. The provider has remained in breach of the legal regulations in relation to people’s safe care and treatment, the way people’s medicines were managed and premises and equipment.

We identified a further breach of regulation at this inspection in relation to staffing concerns.

Improvements were found at this inspection around establishing capacity and consent, and the provider was no longer in breach of the regulation relating to consent.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from avoidable harm and neglect. The provider did not act on concerns quickly and appropriately.

We identified safeguarding concerns, some of which had been recognised and recorded by staff. However, action to mitigate these and keep people safe had not always been taken. This meant people had been left at risk of ongoing harm.

During the assessment 1 person was involved in 3 incidents, 1 of which placed them at risk. On each occasion we needed to intervene to ensure staff supported this person to keep them safe. Although some measures were in place to protect this person from self-neglect, we remained concerned about their welfare, and we raised a safeguarding concern with the local authority.

People were at risk of avoidable harm from falls. One person’s care records had identified risks associated with falls but after observing the risk prevention measures that had been put in place, and after speaking with staff, it was apparent these would not be fully effective in reducing harm to the person. During this assessment we were informed of the revised preventative measures which would be put into place. Up until this assessment, this person had been left at risk of harm.

We reviewed staff recruitment and ongoing supervision and support records and saw there was a failure to monitor and address individual staff concerns when poor care had been identified. The provider told us they had been reluctant to performance manage 1 member of staff due to their potential “heated” response. This staff member had not demonstrated appropriate care towards people. There had been no accountability from the registered person to ensure staff were effectively managed and undertook their role in a suitable manner. This left people vulnerable and exposed to the potential abuse.

We identified that people were at risk of their oral care being neglected. We were not assured that people received regular and appropriate oral hygiene care. We found 2 people’s toothbrushes had not been used during their morning personal care support. Relatives also raised concerns that their family member’s hair was not always washed and that another relative’s oral health had declined and they were not sure their teeth were being cleaned. There were limited care records referencing the provision of oral care and staff told us this was on a to do list.

There were improvements to the assessing and recording of people’s mental capacity assessments to ensure for people who had safety restrictions in place, these had been undertaken appropriately. The majority of people who required these extra safeguards now had mental capacity assessments in place and these had been reviewed and updated. These recorded the decision needing to be made and if the person could retain the information in order to make that decision.

We reviewed the Deprivation of Liberty Safeguards (DoLS) that had been applied for and those which had been authorised. 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'. The registered manager had a DoLS tracker in place for monitoring submissions and authorisations.

Improvements had been made to ensure all necessary notifications were appropriately submitted to CQC. We reviewed incidents and accidents records within the service and saw the appropriate notifications for serious injuries and DoLS authorisation outcomes had been made where required.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not work together well to provide safe care that met people’s individual needs.

Recruitment processes continued to need improvement. The omissions identified in the recruitment process for 1 staff at our last assessment had not been rectified sufficiently. At this assessment we identified another member of staff with employment omissions. The staff continued to work in the home without appropriate risk assessments in place. This meant people were potentially at risk from staff who had not been sufficiently vetted. The registered manager told us they would take action to obtain the missing information.

There had been some staff absences which had been covered by other staff members and agency staff. Although the appropriate processes and agreements were in place some staff were regularly working over 59 hours per week. Some staff also were unable to fulfil their usual role as they were needed to cover other areas that were short staffed. The provider told us that they were in the process of recruiting new staff. The impact of long hours on staff had not been risk assessed.

The dependency assessment tool used by managers to calculate staffing numbers was not reflective of people’s needs and did not take into account the layout of the building. For example, one person had been allocated 5 minutes support, throughout the whole day, for personal care. The provider could not be sure that the home was adequately staffed due to these inaccuracies. We saw impacts of staffing shortages in areas of cleaning and updating records where staff could not fulfil these roles. We were unable to evidence impact on people waiting prolonged periods of time as call bell monitoring was not being monitored and the majority of people were unable to communicate this to us. We raised this with the provider and registered manager who said it would be reviewed.

The registered manager had implemented a training matrix to record staff training. We reviewed this and saw there were large gaps in completion records. This was despite the service’s action plan stating all staff had completed required training. The registered manager told us the matrix was not completely accurate but acknowledged there were still refresher courses being booked to bring staff up to date. This meant we could not be assured the staff team were sufficiently skilled and knowledgeable to undertake their roles and meet people’s needs safely and effectively.

None of the staff team had completed training in learning disability and autism (the Health and Care Act 2022 introduced a statutory requirement that health and social care providers must ensure their staff receive learning disability and autism training appropriate to their role). The registered manager and provider were unaware of this requirement and had failed to adhere to this.

The registered manager confirmed improvements in staff supervisions sessions and staff were positive about this support. One staff commented, “Management is very helpful, feel confident to talk to them [registered manager] is really supportive and have supervisions with her and don’t have to wait can have a chat with her.” The majority of relative comments were positive about staff availability and demeanour. One relative said, “Staff are really good, very attentive with Mum. They could always do more. They are a brilliant team. Always very good when I’ve been here, very helpful and attentive.”

The provider did not assess or manage the risk of infection.

Due to the size of the laundry room, it was hard to ensure complete segregation of clean laundry from items to be laundered. Some actions had been taken to try and improve this and improve the room’s cleanliness. However, there remained concerns around the overall management of infection prevention and control in the service.

The service had been receiving support from an infection prevention and control nurse working under the Integrated Care Board (ICB). We saw some actions identified in a linen audit with a completion date of 17 February 2026, had not yet been taken.

We could not be assured that the service was being cleaned sufficiently and that people were supported to live in an environment that protected them from the risk of infection. We saw large gaps on cleaning records where these indicated no cleaning had taken place. The cleaning staff told us these were days where there had been no cleaning staff available. They told us staff were meant to try and fit in cleaning around care and activities, including other roles they may be covering. Staff rotas showed on days where there were no cleaning staff, no other staff had been allocated to cleaning tasks. One relative told us, “It’s clean, apart from weekends. The cleaner comes alternate Saturdays. Monday morning can be quite smelly.”

There was no recording of rooms receiving a deep clean and no record of mobility equipment or shower curtains being cleaned regularly to prevent them from being an infection risk. One staff member told us, “[Shower curtains] might be done once a week but never known this be signed for and there isn’t anywhere to sign for this.” The registered manager told us, “The cleaning checklists needed revising” and they agreed these needed to be put in place. The shower room identified in the previous assessment as having mould present, had been treated and the mould removed. However, we saw at this assessment the large gaps of missing plaster had not been repaired despite being on the provider’s maintenance plan since December 2025. This area could not been cleaned effectively. We were informed a quote for repair had been received and this would be followed up.

During this assessment we continued to find areas of the home that had strong offensive odours. Despite staff following care plans to support people’s continence needs, the lack of cleaning of soiled chairs when they were vacated, was putting people at risk of infection. We raised this with the provider to address further. One person had a visibly stained bedroom chair. The provider told us they had needed to obtain quotes to have it replaced and staff were cleaning it with disinfectant.

The cleaning staff we spoke with had good knowledge of their role and how to use necessary chemicals and equipment appropriately. They were able to describe the actions they would take in the event of an infection outbreak, and they enjoyed the contact with people their role gave them, commenting, “I can spend time with residents and chat when cleaning. It’s important to interact with people as it’s their home.”

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

Although there had been some improvements to the management of medicines since our last assessment, there continued to be areas of improvement needed to ensure safe practice.

Following the administration of medicated patches staff had not recorded where on the person’s body they had placed the patch. This meant there was a risk that future patches would not be correctly rotated in accordance with the manufactures guidance to prevent skin irritation.

Medicines applied directly to the skin, such as creams and ointments, were not always managed safely. We found examples of these medicines not dated on opening to ensure they were not used past the manufacturer’s recommended time. One person’s medicines were opened in September 2025 and were still in use 5 months past the recommended usage time of 3 months. This meant people were at risk of receiving medicines that were no longer effective.

Some people lived with dementia and were unable to articulate if they were in pain. There was no pain assessment tool in place to support staff to assess and recognise if people required pain relief. This meant there was an increased risk people’s experience of pain would not be suitably managed.

We reviewed the provider’s process for checking staffs’ medicines management and administration competencies. The process was not robust, with staff signed off as competent, without demonstrating this. In addition, the registered manager could not assure us that they had the knowledge and skills to undertake these staff competency assessments. This put people at risk of receiving medicines from staff who were not fully competent to safely manage and administer medicines.

During this assessment the office door was left open with three months stock of medicines accessible. We located a staff member and asked them to secure this door to prevent anyone entering and accessing medicines not prescribed for them and being placed at risk of harm from this.

Improvements had been made to the management of homely remedies (over the counter medicines). Only one medicine was available in the homely remedies stock and pharmacist support had been sought for the management of this medicine.

People’s medicine records had clear protocols in place for staff to follow when administering medicines that were prescribed for use as required (PRN). We saw records were completed following each administration and there were no omissions noted. People’s medicines were ordered and delivered in a timely way.