Oak Hill Mansion

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 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.

The service was in breach of legal regulation in relation to people’s safe care and treatment, specifically regarding the ways people’s medicines were managed.

This service scored 62 (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.

Staff recorded incidents on appropriate forms and the manager reviewed them to make sure changes were made to improve practice.

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.

We saw appropriate referrals being made to other agencies and information was shared to support easy access. The service had a pre-admission policy and pre-admission assessments were contained in people’s records with relevant information.

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.

Although not all staff had completed safeguarding training, staff knew how to raise concerns if required. There was an appropriate policy and information about safeguarding in the office and on notice boards in the corridor.

The manager worked with the local authority to raise safeguarding concerns and support any investigations.

People told us they felt safe living at Oakhill Mansion, and that staff were responsive to their needs. A person said, “I feel very safe here; it’s very comfortable.”

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.

The manager completed risk assessments alongside people and relatives and reviewed them regularly. Staff could access them easily in people’s care records. Staff had good knowledge about people’s needs and risks and could provide the right level of care and support to help someone if they experienced distress. Staff looked at possible causes of people’s potential distress and documented this so that improvements or changes to care could be made if required.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Health and safety checks and environmental risk assessments were completed. These included fire safety, gas, electric and water safety testing. The provider took responsibility for maintaining the premises and the building and equipment was in good working order.

The provider did not always make sure that staff were recruited using safe processes. However, there were enough staff on duty to meet people’s needs.

There were some gaps in staff recruitment records regarding employment history, which had not been followed up by the provider. We fed this back, and the manager agreed to check this immediately. References and DBS checks had been obtained.

The manager and provider had begun to make sure all staff completed relevant training. Staff confirmed they had completed essential training such as moving and handling and end of life care.

The service used agency staff at time, they made sure agency staff were consistent and knew the needs of people well.

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.

There were dedicated housekeeping staff with regular cleaning schedules adhered to. The house looked very clean and tidy. Staff wore suitable clothing to protect against the spread of infection where appropriate such as gloves and aprons. People confirmed their rooms were cleaned regularly and relatives commented they thought the home was maintained to a high standard.

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

Not all staff administering medicines had a certificate to show they had received training, so we were not assured staff had up to date guidance about how to administer medicines safely.

Medicines were not always administered as prescribed. For 1 person records showed that at times they had not received their insulin as prescribed. Required monitoring for insulin had not always been documented so we could not be assured that this person’s diabetes was being managed safely.

Medicines records were not always completed accurately. We found that staff had not always signed to say they had administered people’s medicines, so we could not be sure that people received their medicines according to their prescription. Controlled drugs records were not always completed in line with legal requirements.

People were supported to manage and self-administer their own medicines if they wished, however risk assessments to support this were not available to review at the time of the assessment for 1 person.

There was a system in place for the recording of topical medicines such as creams, however we found these were not always completed accurately.

Time sensitive medicines were administered safely, and guidance for staff about how to administer medicines was in place and person centred.