Three Oaks Residential Care Home

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.

People and their relatives we spoke with were all happy with the service provided. They were confident that if they needed to raise any concerns, they would be listened to and taken seriously.

Staff were encouraged to make suggestions to improve the service. They confirmed learning from incidents was communicated within the staff team to reduce the risk of events recurring.

The provider had systems to monitor accidents and incidents and ensure appropriate actions were taken. There was an updated falls policy, which provided a flow diagram to give staff quick access to the information they would require to safely manage an accident or incident.

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.

Pre-assessment tools were completed. Records showed people were referred to other healthcare professionals when needed. There was a weekly GP review which included input from other members of the multi-disciplinary team, and staff told us it was easy to contact a GP for advice between weekly visits. Records showed people were supported to attend appointments.

Staff told us they worked well with health and social care professionals and had developed good working relationships. There were clear processes to ensure people’s current information was safely shared.

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.

Relatives we spoke with said they believed their relative felt safe living at the care home. Relatives told us they felt able to raise any concerns or worries they might have with staff or the managers.

Staff received training in safeguarding. Staff demonstrated their understanding of safeguarding issues and the procedures for reporting concerns. They expressed confidence in the management team responding appropriately to any concerns they raised.

The registered manager submitted statutory notifications appropriately and worked with other agencies to keep people safe. We saw evidence that recent safeguarding referrals had been made appropriately. Where people were subject to Deprivation of Liberty Safeguards (DoLS), staff knew how to support them as people’s care plans contained information and guidance.

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.

People’s care plans contained risk assessments and guidance for staff on how to manage and reduce risks associated with people’s care and support. Records we saw indicated a thorough process of assessment and review, supported by the daily care notes recorded by staff. Care plans and risk assessments were updated as people’s needs changed and staff were informed of the change via group WhatsApp and staff communications book.

Some people had behaviour support plans, when applicable, and staff were familiar with the agreed strategies. Staff demonstrated knowledge and understanding of individual’s needs and how to manage situations that could potentially cause the person to become anxious.

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 registered manager carried out risk assessments of the home environment. We saw a record of a completed auditing tool, which showed a thorough room by room assessment, with photographs, including trip hazards, call system, water, heating, windows, and cleaning materials. Risk assessments were also seen for Legionella, laundry, drying room, telephone and hot water taps.

There was a Business Continuity Plan located by the front door, which was reviewed annually. The provider had plans for ongoing refurbishment of the environment, and we saw evidence of work completed and in progress.

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.

Comments from people and their relatives included, “They clean in here every morning. I love my room; it’s cosy” and “I’ve never thought of it not to be clean. There are no unpleasant smells.”

Staff had been trained in infection prevention and control and told us there was enough personal protective equipment (PPE) available such as gloves and aprons. There were effective processes to prevent and control infection. Staff knew how to manage infection outbreaks at the service. Cleaning schedules were followed and records showed rooms and equipment were cleaned regularly. Hand gel dispensers and PPE stations were in place around the home.

There were audits in place to oversee the cleanliness and safety of the environment, and the service was visibly clean and tidy. There were appropriate clinical waste facilities and colour coded cleaning materials. Food safety was maintained and kitchen monitoring checks were adhered to.

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.

Comments from people and their relatives included, “They clean in here every morning. I love my room; it’s cosy” and “I’ve never thought of it not to be clean. There are no unpleasant smells.”

Staff had been trained in infection prevention and control and told us there was enough personal protective equipment (PPE) available such as gloves and aprons. There were effective processes to prevent and control infection. Staff knew how to manage infection outbreaks at the service. Cleaning schedules were followed and records showed rooms and equipment were cleaned regularly. Hand gel dispensers and PPE stations were in place around the home.

There were audits in place to oversee the cleanliness and safety of the environment, and the service was visibly clean and tidy. There were appropriate clinical waste facilities and colour coded cleaning materials. Food safety was maintained and kitchen monitoring checks were adhered to.

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.

People’s medicines were managed so that they received them safely. There were procedures and records in place and staff demonstrated knowledge and understanding of the processes. Records showed people had received their medicine as prescribed. Medicines were stored safely. Temperatures of storage areas including medicine fridges was monitored. Regular audits of medicines management were carried out both internally and by an external consultant.

Feedback from an external professional involved in the systems and processes of medicines management told us staff at the home were “Very organised” and “Well informed” in relation to this aspect of the service.

People’s medicines were reviewed annually or sooner if required. The registered manager had introduced a process for tracking this and other medicine matters. This meant people were not receiving medicines that did not effectively meet their needs.

We observed a person asked a member of staff what the tablets were for and the member of staff explained this to them. People were supported to be as independent as possible with their medicines. A family member told us, “They give her a strip of tablets, and she hands back any unused tablets. They let her do it, it suits her much better.”