Oak Field

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 72 (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.

Incidents were recorded within 24 hours and reviewed promptly by the compliance manager. Urgent incidents requiring medical attention were escalated immediately. A professional told us, “I consider the service to be very safe and the risks to be very well managed. I have no concerns whatsoever.”

Behavioural incidents were analysed, and action plans were implemented to address triggers and prevent reoccurrence. Staff took part in handover discussions and debrief sessions to reflect on incidents and identify learning.

For example, one person experienced frequent episodes of distress. Following a GP referral and psychiatric review, a medicine change led to a significant reduction in these incidents.

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.

A healthcare professional told us, “I have always found the care home to be prompt in making enquiries to GPs, health professionals, and Social Care. I have no concerns.” Referrals were managed by the business development team alongside the registered manager. Pre-admission assessments considered people’s health, preferences, and support needs.

People were invited to visit the service to meet staff and familiarise themselves with the environment. Where required, a 2-night transition stay was offered to support a smooth move. After admission, staff reviewed care plans together and received handover briefings to ensure consistent support.

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.

Staff had completed safeguarding training and understood how to identify and report concerns. Staff could tell us about indicators of abuse. They explained it included unexplained injuries, unusual spending patterns, and sudden behavioural changes. One staff said, “everything we do is all about making sure people are safe and protected.” Another staff said where they had concerns, they raised it immediately with the manager [registered] and followed up for it to be reported to the local authority.

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.

Risk assessments were built into care plans and reviewed regularly with input from people, families, and professionals. In response to an increased level of falls, a comprehensive falls prevention plan was created to address individual risks and promote safety. For example, one person with a high risk of falls had a plan stating they must not use the stairs or lift unsupervised. Staff consistently followed this, resulting in a significant reduction in falls.

Staff were trained in Positive Behaviour Support (PBS) and used a range of proactive strategies to help people feel safe and confident. For example, staff used social stories, which are simple, personalised narratives with pictures and short text designed to explain upcoming events or changes in routine. These helped people to understand what to expect in unfamiliar situations, such as attending hospital appointments or meeting new professionals.

This approach reduced anxiety, promoted confidence, and supported people to engage more positively with new experiences.

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.

Environmental checks were completed regularly, including fire safety and equipment audits. The home had a keycode entry and exit system, ensuring safety despite its location on a busy street.

During the inspection, we identified that some fire doors were not closing properly. The provider had been carrying out weekly fire door checks and had already identified faults with several doors. They had logged this as an urgent action prior to our visit. While we were on site, the issue was escalated immediately, and the required repairs were completed before we left the service.

Notwithstanding this positive response, we also observed other environmental concerns. Several floors were uneven, and there were cracks and holes in walls near handrails. In addition, some interior decorations were faded, and surfaces appeared worn and dirty. Although none of these issues had posed any immediate safety risk to people living at the service, we raised our concerns with the provider during the inspection.

The provider responded positively and submitted a service action plan outlining clear timescales and actions to address the issues identified. In addition, we reviewed maintenance records which showed that stair lifts had been serviced as required and were in date at the time of our inspection.

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.

Staffing levels met people’s needs safely, with 5 staff during the day and one waking night staff supported by one sleep-in at night.

Recruitment was managed centrally, with interviews conducted by the Registered Manager. Pre-employment checks were carried out in line with regulations, including Disclosure and Barring Service (DBS) checks and reference checks, to ensure staff were safe and suitable to work with vulnerable people.

New staff completed a 3-day induction at head office, followed by a service-specific induction checklist and mandatory training before working independently. Automatic reminders for expiring training were issued 4 weeks in advance, and a dedicated workstation was available to enable staff to complete updates promptly. Additional training included learning disability and autism awareness to ensure staff had the skills to meet people’s specific needs.

Supervisions were carried out every 6 to 8 weeks and included a range of practical safeguarding and behavioural scenarios to ensure staff remained confident, competent, and consistent in managing concerns and providing safe, high-quality support. Supervision records showed that discussions focused on developing problem-solving skills, reflective practice, and improving staff responses to complex situations.

Staff demonstrated a clear understanding of these principles during observations and discussions. For example, they were able to explain how they recognised early signs of anxiety and adapted their approach to de-escalate situations effectively. One relative told us, “They [family member] have been very settled here compared to their previous placement.” This highlighted how staff knowledge and proactive planning contributed to improved outcomes and a stable, supportive environment for people.

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.

Staff consistently followed the provider’s Infection Prevention and Control (IPC) policies and had completed all required training. Records confirmed that refresher courses were completed on time to ensure staff knowledge remained up to date.

During the inspection, we observed staff wearing appropriate personal protective equipment (PPE), including gloves, aprons, and hairnets when preparing food and carrying out cleaning tasks. PPE was used correctly and disposed of safely in line with IPC procedures.

Cleaning schedules were in place and thoroughly followed. Staff used colour-coded equipment for different areas of the service to minimise the risk of cross-contamination. The environment was visibly clean and well maintained, and we saw handwashing signs displayed clearly at handwash stations and bathrooms across the service, supporting good hygiene practices.

Staff also ensured that fridge and freezer temperatures were checked and recorded consistently to maintain safe food storage and reduce the risk of contamination. These records were up to date and showed that safe temperature ranges were 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.

Medicines were supplied by a nominated pharmacy every two weeks in blister packs. On delivery, medicines were counted, recorded, and stored securely. The Registered Manager carried out weekly medicines audits to ensure records were accurate and any discrepancies were identified and addressed promptly.

When we reviewed electronic medicines administration records (eMARs), there were no gaps, and the alert system ensured medicines were given on time.

Staff had completed medicines administration training and were assessed as competent before being authorised to administer medicines. We observed staff following safe administration practices, including checking medicine records, expiry dates, and prescriptions prior to giving doses.

As required protocols were clear, accessible, and consistently followed, ensuring people received medicines safely when needed. Medicines were also reviewed regularly by GPs and psychiatrists to ensure they remained appropriate and effective.

Notwithstanding these positive findings, during the inspection we identified that some medicines labels were faded and difficult to read. We raised this concern with the provider, who acted immediately by contacting the dispensing pharmacy to request relabelled packs. While no one had come to harm, the provider recognised the potential risk associated with unclear labels and took prompt steps to resolve the issue.