The Oaks 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.

This is the first assessment for this newly registered service. This key question has been rated 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.

We found robust systems were in place which were effective in analysing incidents to drive improvements in the home. All staff were trained and encouraged to record any incidents that they witnessed in real time capturing what they had seen on the electronic recording system. All incidents were then reviewed by management and overseen by the senior management team to ensure actions were taken where needed to mitigate future risks. We found the provider was continuously learning from incidents and sharing lessons internally with the staff team and across the provider’s other services. This shared learning and reporting reduced the likelihood of recurrence of similar incidents.

Monthly meetings called ‘lessons learned meetings’ were held to share learning across the provider’s services and attended by the management team. Minutes from these meetings were shared with us and showed risks relating to medication and falls, had been previously discussed. Most recent meetings showed incident reporting, training, wellbeing and the use of door gates had been discussed. The discussions recorded evidenced staff engagement resulting in suggestions and actions for the management to follow up. This included arranging focused refresher training sessions for improving the reporting of incidents. Comprehensive audits were completed which included audits of all incidents, falls, weight loss, wounds, complaints and safeguarding concerns which were analysed for patterns and trends.

The provider’s robust analysis of incidents had led to service improvement measures being implemented. The actions the service would take to reduce any identified risks or new potential risks for people were clearly documented.

The senior management team focused on learning culture at the service to continually support staff to report and investigate incidents and ensure that any lessons learned were embedded.

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.

The service worked collaboratively with external professionals to ensure safe and well-coordinated admissions, as well as smooth transitions when people required hospital care.

Prior to admission into the home, an initial assessment was completed. Where possible, this was completed face to face in hospital or people’s own homes to ensure that the provider could meet the person’s assessed needs and expectations. One person told us, “The registered manager visited us at home to understand [my relative’s] care needs and likes and dislikes. They were extremely thorough with their questions in order to get to know [my relative] well they asked almost everything.” This process provided reassurance to the family that their loved one was moving into a home where staff already had a clear understanding of their needs and personal preferences.

Care plans were formulated in more detail following detailed discussions with the person and their relatives or representatives. These personalised care plans included comprehensive information such as clinical needs, medication requirements, past medical history, identified risks, allergies, communication preferences, and contact details for those important to the individual. Care plans were reviewed regularly and updated promptly when a person’s needs changed.

When people were admitted to hospital, whether planned or in an emergency, a summary of essential information accompanied them. This ensured hospital staff had accurate details about the person’s health conditions and support needs, enabling them to provide safe and appropriate care.

Several people admitted to the home had complex care needs, and health professionals were actively involved in supporting these transitions. They provided ongoing guidance and interventions to ensure placements were safe and appropriate. A health and social care professional told us, “I have a very good relationship with the staff at The Oaks. They are always open to suggestions and implement any changes to care straight away.”

We found the service worked collaboratively with external partners and professionals to ensure people had a safe admission to the service, or when people experienced a hospital admission.

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.

People were relaxed around staff and told us they felt safe living at The Oaks. Comments included: “I don’t sleep very well. If I am awake in the night the night staff come and chat to me. I feel very safe here. If I didn’t, I would tell the manager and all the staff. I do feel safe because they are all very caring people.” “I feel safe here. It’s the staff who make me feel safe. They check up on me. The management keep the building safe.”

Relatives told us their observations of staff interacting with people gave them confidence their family members were being well looked after. One relative told us, “[my relative] is 100% safe there and very well looked after. I am very happy with the level of care [my relative] gets.”

Staff had received training in safeguarding people from harm and understood their responsibility to report any concerns. Staff told us they were aware of the provider’s safeguarding policy, and a copy was kept in the staff room and could also be accessed via ‘Hippo’ (the provider’s electronic library for policy and procedures) via their handheld devices. One staff member told us, “If I witnessed a safeguarding [incident], I would document it and then escalate it to the manager. I would contact [the] safeguarding team, and I would document what has happened and what I have done through [the] Nourish system which triggers the triage system.”

The provider reviewed all safeguarding concerns to ensure the right actions had been taken to maintain people’s safely.

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 and those important to them, including health and social care professionals, told us they were actively involved in planning how risks were managed to keep individuals safe. Risk assessments were developed collaboratively and tailored to each person’s needs, ensuring that strategies reflected their preferences and circumstances. These assessments were reviewed regularly and updated promptly when needs changed. This approach helped maintain safety while promoting independence and dignity. Professionals confirmed that staff followed agreed procedures and communicated effectively to manage risks consistently.

People with specific health conditions were supported effectively to reduce the risk of avoidable harm. Risk assessments were in place to ensure safety while promoting independence and dignity. People who preferred to move freely around the home were encouraged and able to do so because staff followed clear guidance and implemented measures that balanced risk with personal choice. Care plans contained instructions for staff, ensuring that people’s needs were met safely and consistently.

The service supported people living with dementia, and staff demonstrated an understanding that people might sometimes become distressed. Staff we spoke with were able to describe the steps they took to identify triggers, provide reassurance, and support people to express their emotions in a safe and respectful way. This included adapting communication methods to meet individual needs. For example, the provider promoted the use of British Sign Language (BSL) and delivered associated training for staff, people living at the home, and their families. These approaches helped reduce anxiety and ensured that people were supported in a way that respected their preferences and enhanced their wellbeing.

Technology was used to help manage risks, including acoustic monitoring and sound sensors to track movements when people were alone in their bedrooms. For example, this reduced intrusive night-time checks for a person which had led to improved sleep, increased confidence with mobilisation, and enhanced overall wellbeing, while maintaining safety and respecting the person’s independence. The person’s relatives reported that the person was much happier and more settled overnight and less anxious about mobilising. Another person living with dementia explained that routine night‑time checks caused significant anxiety and disrupted their sleep. The team involved them and their family in planning support, agreeing to avoid routine checks and instead use the acoustic monitoring system as a safe, least‑restrictive way to meet their needs. Medication times were also adjusted to avoid night‑time disturbance. This meant the person now slept peacefully, their anxiety had reduced, and they felt settled and confident enough to join others in the dining area again. This demonstrated how involving people in decisions about risk can greatly improve wellbeing, safety, and trust.

These systems enabled staff to respond promptly if assistance was required or in the event of an emergency. We also found that some people had chosen to have a door gate fitted to their bedroom to reduce the risk of others entering. This had been risk assessed and documented in their care plan. One person told us, “I like the stairgate as it stops people, I don’t want them coming in, the gate makes me feel 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 provider ensured the new-build care home was well-designed in line with dementia-friendly guidance. The environment featured abundant natural light and wide corridors to promote safety, comfort, and ease of navigation. Each floor included multiple communal lounges and dining areas, as well as smaller rooms suitable for people living with dementia. There were quiet spaces for people to spend time alone or with family and friends. The external grounds around the home were secure, with seating areas and planters and we observed these being used during our assessment.

The home incorporated safety features consistent with Health and Safety Executive (HSE) guidance to protect people. Windows were fitted with restrictors, furniture was secured to walls to prevent accidents, and specialist equipment such as falls sensors and air mattresses was in place and well maintained where required.

Maintenance concerns identified were raised through the provider’s online system (Radar), which generated an alert for action.

The home employed a dedicated maintenance team who completed repairs promptly and undertook regular safety checks, including fire doors and water systems. Routine audits were carried out weekly, including fire alarm checks, fire evacuation drills, and water temperature monitoring. However, during the inspection, we identified missing documentation for fire drills and evacuation records, as well as red ratings in the Fire Risk Assessment and Aqua report, which initially indicated non-compliance. This was bought to the attention of the management team who responded immediately. These issues were due to documents not being presented during audits rather than an absence of evidence. The provider has supplied the missing documentation, demonstrating compliance. Learning has been taken to improve audit processes and ensure documents are readily available for future checks.

There were 2 emergency fire alarms on day 2 of the inspection due to a fault in the system. We found the evacuation was conducted professionally by the fire marshals and the fault was found on the system and addressed.

The kitchen was managed to a high standard of hygiene. The local authority food safety officer had awarded the home a five-star rating in 2024, the highest possible score, confirming that food hygiene standards were very good and fully compliant with legal requirements.

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.

People and those important to them told us there were enough staff available to meet their needs, and most felt staff were visible and responsive. Some relatives suggested additional staff may be helpful during busier times. We observed that staff were not rushed when carrying out their duties and there was a calm, organised atmosphere throughout the home, which contributed to a positive experience and demonstrated that staffing levels were appropriate to meet people’s needs.

We shared this feedback with the provider who confirmed that a dependency tool to monitor staffing levels was completed by the staff for transparency and reviewed by the management to ensure the correct level of staff were on rota to meet people’s care needs. We reviewed the rota and found that there were sufficient staff to cover the care needs of people at the service The provider evidenced where additional staff had been added to the rota. For example, the third floor was divided into 2 ‘households’ following analysis of incidents which demonstrated that the management team was reviewing data to ensure staffing levels were correct.

Staff were recruited safely, and records confirmed all required checks were completed. The recruitment process focused on selecting individuals with the right values and emotional intelligence, and staff described the experience as positive and supportive. Induction included shadowing, face-to-face training, and access to policies and procedures.

The provider invested in staff development and offered a range of opportunities to enhance skills and knowledge. This included a comprehensive induction programme, advanced dementia training, apprenticeships, and mentoring to support clinical skills. Some staff were undertaking courses to deliver internal training in areas such as ‘Soul Midwifery,’ which focuses on holistic and spiritual support for people on a palliative care pathway. Workshops were provided on person-centred care and the impact of emotions on behaviour and communication. Nurses received resilience-based clinical supervision to help manage stress and reflect on practice.

Training records showed staff had completed all mandatory training, including dementia care and communication support. All staff completed refresher training called ‘Remember our why’ after 1 year in post, reinforcing the home’s values and ethos. This benefited staff by strengthening their understanding of person-centred care, boosting morale, and ensuring consistency in delivering compassionate, value-driven support. It also helped maintain a positive culture where staff felt connected to the home’s mission and motivated to provide high-quality care.

Care champions were in place for areas such as nutrition, oral health, wound care, and dementia, promoting best practice and supporting colleagues.

We observed staff using their skills and knowledge effectively, providing calm, dignified, and person-centred care. People told us they felt safe, and relatives expressed confidence in the care provided. The provider demonstrated a commitment to training and development, ensuring staff had the skills and confidence to deliver high-quality, compassionate care.

Staff were several different coloured t-shirts as uniform. The intention behind this was to eliminate barriers creating comfort and no label of hierarchy.

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.

People and their relatives told us the home was clean and well maintained, with 1 relative commenting, “It is spotlessly clean.” People said their bedrooms and communal areas were cleaned to a high standard, and any issues were addressed promptly. Relatives confirmed they were informed of any infection outbreaks by email and notices at the entrance.

We observed the home to be clean throughout. Housekeeping staff, referred to as home makers, were deployed across the service and followed detailed cleaning schedules, which were signed and up to date. They had received training, had access to appropriate equipment, and demonstrated strong knowledge and passion for their role.

Staff understood infection prevention and control measures, including correct use of personal protective equipment (PPE), and confirmed PPE was readily available. Training records showed staff received regular updates on infection control practices.

The provider completed regular internal audits to monitor cleanliness and the condition of equipment such as pressure cushions and mattresses. External healthcare professionals told us they had no concerns about infection prevention and control and described the provider as open and willing to engage.

Housekeeping staff described the additional measures introduced following a small outbreak in late 2024. This included the introduction of outbreak boxes containing dedicated IPC Infection prevention control equipment for individual rooms to prevent cross-contamination.

Laundry processes were robust, with clear procedures for washing soiled items and checklists for cleaning mattresses and hoist slings. Mattresses were cleaned weekly, and slings were cleaned on a rotational basis or as required, with records detailing dates, serial numbers, and room numbers. Communal areas were cleaned 3 to 4 times daily, and deep-clean schedules were in place. Systems for recording cleaning and laundry tasks were thorough and consistently maintained.

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 told us they received their medicines when they needed them, with 1 person commenting, “I am very happy with how my medication is administered. The nurses are very good; they come round like clockwork.” Care plans and risk assessments provided clear guidance on how people preferred their medicines to be given, including instructions for ‘as required’ medicines to manage pain or distress.

We observed medicines being administered safely. Medication was securely stored in people’s bedrooms, and opportunities for self-administration were assessed when people moved into the home. For people who lacked mental capacity and required covert administration, care plans were in place and supported by mental capacity assessments and best interest decisions involving relatives, healthcare professionals, and staff. Pharmacy instructions for covert administration were documented in electronic care plans accessible to staff.

Medicines were ordered, stored, and recorded safely using an electronic system, with contingency plans in place for system failure. Controlled drugs and supplements were stored securely in the medicines room, and medication fridges were monitored with temperature checks recorded and within safe limits.

People’s medicines were stored in their private bathrooms in medicine storage box’s which were secured to the wall and accessed via secure key code. The provider’s medicines policy covered all associated risks including moisture and temperature checks with contingency plans.

Medication was recorded on an electronic system, ‘EMAR’, enabling a record to be made in the daily log for each person on the Nourish system (a digital care management system). The service had a backup plan in case of technology failure, and this was evidenced with copies of printed-out drug records stored in clinical rooms.

Clear key coded boxes were used to store drinks thickener, clearly labelled with the person’s details and laminated instructions for use. Medicines were administered by registered nurses and trained care companions, all of whom had completed robust medication training and competency assessments, including observed practice by senior staff. Not all care companions were trained to administer medicines; however, training was offered to those who demonstrated capability or expressed interest in developing their skills in this area.