Oat Hill 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 newly registered service. This key question has been rated 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.

This service scored 59 (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. Lessons were not always learnt to continually identify and embed good practice.

We saw examples of leaders responding appropriately when issues were identified during the inspection, and some immediate action was taken to address concerns. For example, issues relating to mattresses and bedding were remedied quickly and leaders introduced new oversight arrangements which a named member of staff was to oversee. Leaders also told us they had ordered wipes to strengthen hand hygiene prior to meals and described steps they were taking to improve practice.

The provider had a Safety Incident Response Framework, internal meetings, supervision processes and mechanisms to promote openness such as Duty of Candour and the “Speak Out” helpline. These demonstrated processes were established to support learning, transparency and continuous improvement.

However, learning and oversight were not consistently effective in identifying and addressing safety issues prior to inspector intervention. This was particularly evident in relation to medicines management and aspects of infection prevention and control. This meant the provider could not always demonstrate learning from errors and near misses was embedded into practice in a way which prevented recurrence and provided consistent assurance to people.

A staff member told us, “Yes we have received a lot of training related to safety, and if we have any concerns, it is resolved promptly.”

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.

Leaders provided health and safety paperwork promptly and comprehensively, which supported assurance in this area. The service also had a robust business continuity plan which was detailed and regularly updated, and this supported effective planning and continuity. Staff demonstrated good knowledge of people’s day-to-day needs, and we saw evidence of systems which supported continuity of care.

Relatives were complimentary of the process when their family member required a hospital admission or discharge back to the service. One relative said, “The home phoned me immediately and asked if I wanted to go with family member and I got there to accompany them. The staff were amazing.” Another relative stated, “[Family member] had a [medical procedure] everything went well, we brought [family member] back and was made comfortable and supported until they recovered.”

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.

We observed staff to be caring and respectful in their interactions with people. One person told us, “I feel safe because there is someone you can turn to.”

Some people living at the service had a Deprivation of Liberty Safeguard in place. This meant the decision for where they lived and some restrictions on their daily lives had been approved by authorities, because the person was unable to make these decisions themselves. Some of the authorisations had conditions attached which the provider had to meet. We reviewed records in relation to this, and found the provider was meeting the conditions which had been set.

The service had accessible information in place, including easy read DoLS information, which supported people to understand restrictions and their rights. Staff had received safeguarding training and could describe safeguarding processes including how they would respond if a concern was raised.

A relative told us, “The deputy (manager) is excellent and the (registered) manager has been very helpful and is always available and approachable and knowledgeable on the DoLS process.”

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.

Staff demonstrated good knowledge of people’s needs and how risks were managed, including around eating and drinking. For example, staff could describe practical details such as the size of a person’s drinking glass and how this supported hydration monitoring.

Diabetes care plans were robust, and updated regularly, and we saw clear information for people with continence aids.

We did find one person’s pressure relieving mattress to be set to the incorrect weight, however, the registered manager acted immediately to rectify this.

A relative was asked if they felt their family member was well cared for and they stated, “Yes, they have safeguarding reviews and risk assessments and they had a fall a while ago, their cognitive ability to move is restricted and staff have gone to a hoist now, and now and again just using their walker. Crash mats and alarms in their room, lots of things to keep them safe.”

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.

The home was nicely decorated, well presented and provided a range of amenities people and relatives valued. However, we identified some environmental issues which required attention, including staining and flaking paint to the ceiling in one ensuite, build-up of limescale noted on the bottom of a shower chair, and minor limescale on taps and a stain on a ceiling in another ensuite. These issues did not present an immediate risk to people but required timely action to ensure the environment remained fully safe and well maintained.

People’s bedrooms were personalised. One person stated, “I thought that’s great – I knew I could bring stuff to make it look more like my home – my pictures and paintings.”

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.

A relative said, “[Family member] is safe and well-cared for and [staff] are incredibly patient with [family member] who can be rude to staff and they brush it off.” We observed enough staff onsite to meet people’s needs and respond to call bells in a timely manner.

Staff told us they felt supported by their team leaders and supervision was regular. Staff spoke positively about induction processes and team culture. A staff member stated, “I got the best induction.” Care staff reported their workload was manageable, and relatives told us they did not feel their family members were rushed by care staff.

Staff were recruited safely, and mandatory checks were completed prior to staff commencing employment. Training compliance was mostly good, and staff were able to describe the training they had completed.

Feedback about staff was positive, with comments such as, “They are friendly, caring and approachable and really get to know all their residents.” and “They are all brilliant, friendly and patient.”

A leader within the service stated, “We have a good team and good bank staff, who will pick up extra shifts when short. I plan the rota at least two weeks ahead, looking at levels and putting any extra shifts out to be picked up. We do not use agency staff, nor have any intention to do so.”

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.

We found some issues were addressed promptly when identified, including the mattress and bedding concerns, and leaders put in place improved oversight arrangements. Staff told us they understood how to manage infection outbreaks, and PPE was seen in use, with relatives also reporting staff wore PPE. One staff member explained, “We wear PPE during personal care and if any bodily fluids are present, we take it off in the correct manner and dispose into a bag which is taken to the sluice room and put into a no touch bin with a yellow bag in. There is always plenty of PPE.”

However, practice and assurance were not fully consistent. Staff provided different responses about how mattresses should be cleaned, which indicated inconsistency in knowledge and approach. Cleaning staff told us they were short staffed and “run ragged,” which affected the ability to maintain consistent cleaning standards. We also identified hygiene and maintenance concerns in some ensuite areas. Leaders told us wipes had been ordered to support hand hygiene prior to meals. These shortfalls meant the provider could not fully assure infection risks were always managed consistently to reduce the likelihood of contamination and transmission.

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

People received their medication in tablet form safely and correctly. However, where medication was in alternative formats such as creams or eyedrops, concerns were identified. We reviewed a sample of medicine records from both floors of the service and found an issue with eyedrops on both floors. For example, 1 person was administered eye drops past the recommended discard date until this was raised with the staff member during the inspection.

Recording systems for topical medicines (creams and lotions) were not robust. Whilst Topical Medicine Administration Records (TMARs) were in place, topical application was not consistently recorded correctly. When examples were requested by the inspection team, these had not been completed accurately, and leaders could not rely on records to evidence creams had been applied as prescribed. The deputy manager advised they were going to take actions to improve this moving forward.

Concerns were also identified in respect of disposing of unused medicine, particularly controlled drugs. A person had recently passed away, and the pharmacy had not yet collected their controlled medicines, however, the controlled drugs book recorded the count for all of these medicines was zero. More controlled medicines had been delivered after the person passed away and these had not been booked in. This opened up the potential for these high-risk medicines to be stolen or misused. When inspectors counted, all controlled drugs were present and correct, and the registered manager immediately updated the records, However, this risk had not been identified prior to the inspection.