Oake Meadows 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 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 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a proactive and positive culture of safety based on openness and honesty. Lessons were learnt to continually identify and embed good practice. Incidents, accidents and safeguarding concerns were reviewed, discussed and used to drive improvement. There were systems to monitor events through daily flash meetings, weekly governance meetings and audits.

Staff told us they had a learning culture. One staff member told us, “We try to understand why it [an incident] happened and take measures to ensure it doesn’t happen again. We tell the nurse who tells the manager and they take any necessary action.” The registered manager described how lessons learned from incidents and safeguarding investigations were shared through supervision, team meetings and governance processes.

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.

People were supported through safe transitions between services. The provider worked closely with hospitals, health professionals and therapy teams to ensure people moving into the service had their needs assessed before admission and appropriate care planning was completed. On the rehabilitation unit, staff described structured admission and discharge processes, multidisciplinary working and regular meetings to review people's progress and plan safe discharges. Hospital packs, transfer information and care records contained important information to support continuity of care. Health professionals told us communication was effective and that staff worked collaboratively to achieve positive outcomes for people. These arrangements helped ensure people's needs were understood and risks managed when moving between services.

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 protected from abuse and avoidable harm. People and relatives consistently told us they felt safe living at the service and spoke positively about the care provided by staff. One person told us, “I am really well looked after and yes, I do [feel safe].” A relative told us, “The staff are lovely, they treat [name of person] very well, I don’t have any issues.”

Staff demonstrated an understanding of safeguarding procedures, knew how to recognise signs of abuse and were able to describe reporting processes. Most staff understood both internal and external escalation routes, although 1 staff member was not fully aware of external reporting arrangements.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that where people needed to be deprived of their liberty to keep them safe, the provider ensured a DoLS authorisation had been made., This meant people’s rights were fully respected.

The service did not consistently work well with people to understand and manage risks. Records did not demonstrate all risks to people's health, safety and wellbeing were fully assessed and monitored. For example, 1 person who was at high risk of skin pressure damage had inconsistent information in their care plan on how often they should be repositioned. We identified 7 pressure mattresses were not set at the correct level. Inconsistent repositioning guidance and incorrectly set pressure mattresses place people at risk of skin pressure damage developing. We did not however identify any concerns regarding pressure damage and staff took immediate action to rectify the concerns. We discussed the incorrect pressure mattress settings with the registered manager. They told us mattress settings were checked during their daily walkarounds. The provider told us they were purchasing pressure mattresses with automatic weight settings across the organisation to reduce the risk of recurrence.

Individualised risk assessments were not always in place for when people left the home. One person’s care plan did not include information relating to the triggers to their anxiety or how staff should respond. Staff described how they supported people when they were becoming anxious. One staff member told us, “We reassure people, have a chat, it can take time, but we usually manage to calm a situation.” One visiting professional told us, “Staff appear to be aware of risks and how this should be mitigated.”

Risk assessments and care plans covered areas such as falls, pressure care, nutrition and mobility. Staff understood individual risks and the measures needed to reduce them whilst maintaining people's independence. The registered manager provided examples of how people were supported to take positive risks and make informed choices.

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

Health, safety and environmental checks were in place for equipment, water, fire, gas and electrical safety. An external fire risk assessment had recently been completed and identified actions. The registered manager told us these were being addressed.

During the assessment, we identified exposed pipework that posed a potential scalding risk. The registered manager took immediate action to address this. Servicing and portable appliance testing for 1 piece of equipment had been due in August 2026 and was not completed. We raised this with the registered manager, who told us they would address it. Some areas of the home required refurbishment. The provider had refurbishment plans in place with ongoing work completed.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development.

Most of the feedback we received from people and relatives confirmed there were enough staff available to meet people’s needs. One person told us, “There’s plenty of staff here.” Another person commented, “I’ve got a call bell; I press that and they come. They take their time when they come and help me, they’re marvellous.” One relative told us, “[Name of person] has got a thing beside their chair they can press. They do get a good response.” One person commented,

‘‘Staff don’t come as quick as I’d like when I press the buzzer, I have a call button, sometimes they take a while, but they’re not rushed when they do come. I think there’s enough staff, they’re all so busy. If I needed something they would help me.”

On day 1 of our assessment, we observed staff were busy in 1 area of the home and heard several call bells ringing. However, we did not identify any impact on people. On day 2, this area was less busy, fewer call bells were ringing and staff responded to them.

Some staff commented they could be busy at times; however, they felt there were enough staff to meet people’s needs. One staff member told us, “It depends on the day, when we are with someone and a buzzer goes off, we go and say we will be back in 5-10 minutes.” Other comments from staff included, “Yes there are enough staff and [people’s] 1-1 hours are covered” and “There are enough staff to meet people’s needs.”

The provider had a staffing dependency tool to determine staffing levels and this was kept under regular review. They also had a system in place to monitor call bell response times.

Staff received a range of training relevant to their roles and described comprehensive induction, supervision and ongoing learning opportunities. Training included supporting people living with dementia and 1 staff member described this training as, “Really good training.” We identified some gaps in staff training records; the registered manager confirmed training dates had been booked to address these.

Recruitment processes helped ensure staff were employed safely.

The provider did not consistently manage the risk of infection. Parts of the environment were worn and in disrepair, including damaged flooring, chipped surfaces and stained carpets, which could impact effective cleaning. We identified some gaps in cleaning records and noted isolated concerns relating to environmental cleanliness, odours and housekeeping. Although plans were in place to improve the environment, further action was needed to ensure infection prevention and control measures were consistently effective across the service.

Staff received infection control training. Staff had access to the personal protective equipment (PPE) they required and were observed to be wearing this throughout our visits.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

People and relatives were happy with how people were supported with their medicines. One person told us, “Yes, they sort it out every day, the medication I have to have. They do tell me what I am taking and it’s on time.” A relative told us, “They’re very good with [name of person’s] medication.”

Medicines were generally managed safely, with appropriate arrangements in place for their storage, administration, disposal and monitoring. A visiting professional told us, “Medicines are generally managed safely, and staff engage well with medication reviews and raise concerns when required.”

We identified an issue where prescribed thickening product intended for 1 person had been used for more than 1 person. The product was the same prescribed product for each person; however, this is not good practice. The provider took immediate action to address this and reduce the risk of recurrence, helping to ensure medicines continued to be managed safely and effectively.

Staff had clear instructions to help them give medicines correctly, including medicines that need to be given at specific times, creams and medicated patches. Some of the records for medicines needed when required ‘PRN’ lacked detailed instructions for staff on when to give them. We spoke to the nurse who was aware of how and when to administer these medicines.

Medicines were stored securely, and storage temperatures were checked in line with national guidance to ensure medicines remained safe and effective. We identified 1 area where a fridge temperature was recorded as running higher than the recommended temperature. We discussed this with the clinical lead who told us they would address this.

Medicines requiring additional security were stored securely, with routine checks carried out to confirm stocks were accurate. Disposal methods of these medicines in 1 area of home were not always clearly recorded. We discussed this with the clinical lead who told us they would address this.

Staff responsible for the management of medicines confirmed they received regular training in medicines management and had their skills assessed to ensure they remained competent. Managers and trained staff also carried out regular audits and monitoring checks to help maintain safe standards and practice.