Oakleigh 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 inspection, we rated this key question good. At this inspection the rating has changed to 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 and the ways people’s medicines were managed safely.

This service scored 50 (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. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The service did not consistently demonstrate an effective learning culture. Although incidents were recorded and reviewed, concerns relating to safeguarding, risk management and oversight had not always been identified or addressed through the provider's own systems. This reduced assurance that opportunities for learning and improvement were consistently recognised and acted upon.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Systems were not consistently effective in ensuring people received safe and appropriate support. The provider had processes in place to assess people before they moved into the service, including pre-admission assessments and opportunities to visit for a taster session.

However, these processes were not always effective in practice and did not consistently ensure that people's needs could be met safely and appropriately within the service. We identified examples where people were living in an environment that may not have been best suited to their needs. A healthcare professional also raised concerns that some people's needs were not fully compatible with the service. Leaders recognised these concerns and told us they were working with relevant professionals to support people to move to more suitable placements.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

People were not always protected from the risk of harm. Staff were able to describe what safeguarding meant and how to report concerns. However, safeguarding processes were not always followed consistently in practice. We identified concerns that had not been formally referred or escalated through safeguarding procedures in a timely way. This reduced assurance that people would always be protected from the risk of harm.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people's health, safety and wellbeing were not consistently assessed, monitored or managed. Care plans and risk management records did not always provide sufficient guidance for staff, and staff did not always follow care planning instructions. Behavioural risks were not consistently monitored, diabetes monitoring was not always completed in line with care planning guidance, and people in distress were not always supported in accordance with their assessed needs. This reduced assurance that risks were consistently identified and managed to keep people 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.

We reviewed emergency evacuation records and found inconsistencies in some Personal Emergency Evacuation Plans (PEEPs). Information about people's evacuation requirements was not always clear, reducing assurance that staff would have accurate information available in the event of an emergency.

The environment was not always managed safely. We identified fire exits that were obstructed by equipment and clutter, and medicines cabinets positioned in front of an exit route. Staff were also unable to provide clear assurance about some fire safety arrangements, including emergency evacuation procedures.

Following these concerns being raised, the provider developed and implemented an action plan. During the inspection, we saw evidence that most actions had been completed, which improved assurance that environmental risks were being addressed.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,

supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The provider had systems in place to recruit staff safely. Staff employed at the service had undergone appropriate pre-employment checks, including Disclosure and Barring Service (DBS) checks. Staff also received training relevant to their roles.

However, relatives raised concerns about the use of agency staff and the impact this had on continuity of care. Staff described challenges during busier periods, and people did not always receive support in a timely way. This reduced assurance that staffing arrangements consistently supported the delivery of safe and effective care.

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.

The provider had systems in place to support infection prevention and control, including cleaning schedules, a dedicated laundry room and signage promoting good hand hygiene.

However, these arrangements were not always effective in practice. We observed a strong urine odour in communal areas during the inspection, which reduced assurance regarding environmental cleanliness and monitoring arrangements.

The provider recognised the need for further environmental improvements, including redecoration, and began taking action to address concerns identified during the inspection.

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

Medicines were not always managed safely. We found people were prescribed 'when required' (PRN) medicines without clear protocols in place to guide staff on when the medicines should be administered, the expected outcomes, or when further action should be taken. This reduced assurance that medicines were always administered consistently and safely.

People generally received their medicines on time, and staff demonstrated knowledge of the medicines people were prescribed. Staff administering medicines wore a tabard to reduce interruptions, which helped support safe medicines administration.