Oldham House

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 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.

The registered manager investigated incidents, accidents and complaints to see if anything could be done differently and to learn from these events. Findings from investigations were shared with staff in team meetings, daily handover meetings and through staff supervision. This helped to promote a culture of openness.

The service had CCTV in the communal areas and in the corridors. In the event of an incident such as an unwitnessed fall, the footage could be viewed to help understand what had happened and prevent it happening again.

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.

The registered manager carried out a full assessment of people’s care needs before they came to live at the service. This ensured their needs could be met by the care team. When people were transferred to hospital from the home, the registered manager ensured all relevant information about the person’s care and support needs and any medicines they used were shared with the hospital in a dedicated ‘hospital pack.’

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 generally happy with the care and support provided at Oldham House. One person told us, "I feel safe in here. I like the staff, and I get on with the other people and the nurses. I get on with everyone, really." A relative said, “Overall, it is fine for her here. I have had relatives in other homes, so I have something to compare it to and this is the best home out of them all."

Staff had completed training in safeguarding and knew how to identify and report abuse. One staff member told us, “I would initially speak to the resident, try and determine what has happened, check they are not injured, then document what has happened and report this the manager. I would then report it to the safeguarding team. Sometimes the [registered] manager will do this, but it is also one of my responsibilities.”

The management team had a system to document and report safeguarding incidents. This included reporting to the local authority safeguarding team and the CQC.

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.

Care records contained a range of generic and individualised risk assessments, which assessed risks to people, such as the risk of choking, falling, or behavioural risks and explained how these should be managed. People identified as being at an increased risk of skin damage had pressure relieving equipment, such as specialised mattresses and cushions, to protect them from developing pressure ulcers.

The provider had systems in place to detect and control potential risks in the care environment and ensure equipment, facilities and technology supported the delivery of safe care. However, recording of checks and actions taken when issues had been identified required strengthening.

The provider was in the process of transferring from paper-based records to an electronic system. As such, records were currently spread across a number of systems. Safety certification, such as for utilities were up to date. Water safety checks, to reduce the risk of a legionnaire’s disease, had been completed in line with guidance.

A fire risk assessment had been completed in January 2025, by an external company. We noted 10 areas of concern had been identified, which needed to be addressed within 8 weeks. The provider shared an action plan which indicated 9 of these areas had been addressed, although the date of completion was not included on this document, to confirm the required timescales had been adhered to. We noted monthly checks of fire doors had identified the same issue for the last 5 months, this being some doors had gaps between the door and door frame which exceeded the recommended allowance. There was no record of what action had been taken to address this issue. The provider told us their Estates team had considered the risk to be minimal, due to the presence of smoke seals around the door frames. However, it was not made clear why audits continued to identify this as an issue.

Each person had a personal evacuation plan which explained staff what support they would need to safely evacuate the premises.

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.

The provider operated a thorough recruitment process. Checks were undertaken on new staff before they started work. This included checking their identity, their eligibility to work in the UK, obtaining two references and carrying out a Disclosure and Barring Service (DBS) check. DBS checks help prevent unsuitable people from working with vulnerable people.

The provider had systems to ensure training was kept up to date, and staff were supported through induction, supervision and ongoing development. New staff completed an induction programme, which included face to face and on-line mandatory training. Comments from staff about training included, “We have enough training and it’s in the right areas. Sometimes e-learning and sometimes face to face” and “Training is good. The [registered] manager checks we are up to date, tells us what we need to do.” A relative commented, "I have found it [the service] to be a very good place for [person] from day one. The staff do seem well trained in looking after [person].”

The provider used a system for determining staffing numbers, which was based on people’s needs. Staff rotas were compiled in line with this information, with gaps due to sickness or annual leave filled by staff working overtime or by agency staff. The management team told us they had recently increased the number of staff working the night shift following analysis of incidents that had occurred during the night.

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.

Overall, the service was clean with appropriate infection, prevention and control processes in place.

Checklists were in place for housekeeping staff to follow, to ensure communal areas and bedrooms were kept clean. Bathrooms and toilets, all contained hand hygiene guidance, liquid soap and paper towels, with foot operated pedal bins for disposing of rubbish. Personal protective equipment (PPE) was available for staff to use as and when required. Guidance on how to safely put on and take off PPE was on display around the home.

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

All care staff completed on-line medication awareness training and staff who administered medicines did additional training to ensure they were competent to use the electronic medicines system. An up-to-date medicines policy was in place and regular audits were completed which helped to identify any medicines issues or errors. Medicines errors were investigated and action taken, which included refresher training and further competency checks. Medicines were stored safely, and the treatment room and fridge temperatures were monitored regularly to ensure all medicines were stored at the correct temperature.