Archived: Langley Oaks

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

This service was previously rated good. We rated this key question as Requires Improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. The provider had processes and systems in place, however, they did not always follow their own procedures to ensure people were always kept safe.

The provider was in breach of legal regulation relating to safe care, treatment, and staffing..

This service scored 59 (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. Managers listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider had procedures in place regarding reporting and analysis of accidents and incidents. The registered manager reviewed accidents and incidents, which included a 72-hour monitoring process after a person had a fall. This helped to identify any trends or patterns to inform any changes that may be needed to improve people's care and reduce the risk of falls. The registered manager oversaw complaints, and the service’s development plans included actions identified in audits, quality assurance processes and feedback. Action points included a target completion date and who was responsible for them.

During our inspection, we found the service fostered a culture of learning, improvement and openness. Poor practice was addressed promptly to ensure staff learnt lessons and could correct things quickly for their self-improvement, which provided better outcomes for people. Feedback from staff was also encouraged. Staff told us they were asked to provide their views for improvement during team meetings and reflective practice and during handovers for the registered manager and deputy manager to act on. The registered manager was committed to lessons being shared and used to improve the service.

The provider did work with people and healthcare partners to establish safe systems of care, in which safety was managed or monitored. However, they did not always follow this process. We saw inconsistency in admission processes and the assessment and management of risk.

On review of people’s admission to the home 1 person’s record showed a pre-assessment was completed, and it was clear in discussion with the Registered Manager that they understood the needs of the person well and had a robust plan in place to manage their care safely. This included a multi-disciplinary plan with other professionals to review the assessment as their care needs had increased post admission. However, another person’s record we reviewed showed a pre-admission assessment was not completed, and this meant the provider had no initial risk assessment documented. A subsequent risk assessment was completed 18 days after the person’s admission date. This meant the provider had not fully assessed the individual’s needs and put actions in place to mitigate any risks of harm before the person was admitted to the home. To give a further example, another person’s care record showed a care plan was not completed until 32 days after admission. This meant we could not be assured the provider consistently followed their own procedures to fully assess and mitigate risks of avoidable harm to people when they were admitted to the home.

This was a breach of Regulation 12 Safe Care and Treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

However, this was not the experience of everyone and a relative told us, ‘The manager discussed [person’s] care needs with me when they moved in. It's always an accessible open door, with ongoing conversations happening as needs arise. They [the provider] came out to us on an initial assessment before [person] went into respite care and then again before the ongoing long term care arrangements. I'm involved in decision making.”

The provider did not always work well to ensure people were safeguarded from abuse and avoidable harm. They did not always ensure they protected people’s right to live in safety, and free from avoidable harm and neglect.

We observed occasions when care staff were not present to support and ensure people were safeguarded from avoidable harm, especially when team leaders were completing their rounds and at mealtimes, but also at other times during the day. For example, on a tour of the home with a manager they needed to intervene to support a person who was distressed by a floor spillage, as this had not been seen by care staff who were busy with other tasks. Care workers told us that sometimes there were not enough care workers. Comments from staff included, “There can be problems with not enough staff at certain times of the day such as at lunchtimes, when some people are having lunch in the dining room and others who are cared for in their room or bed” and “Because many people here need individual support with eating, 2.5 staff on duty just doesn’t provide enough support for people”. Another staff member reported “The nurse administers medicines to people at lunchtimes, which means there are only 2 of us to support 10 people, many of whom need individual support with eating.” This is also referred to later in this report, under safe and effective staffing.

Relatives told us staff were busy, and engaged in tasks, for example, one relative explained, “Many [people] are unable to do anything independently, so the staff are fully occupied being task-driven.” We reviewed 8 people’s care records against a dependency tool the provider used to calculate safe staffing levels. We saw examples where people’s care needs were different to the information in the dependency tool record. For example, we found 2 care records which noted people were at risk of choking and required support at mealtimes, but this was not reflected in the dependency tool. This meant we could not be assured there were always enough care workers on site to meet people’s immediate needs, and keep them safe from avoidable harm, such as the risk of choking.

People can only be deprived of their liberty with appropriate legal authority. In a care home this is 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 the provider did not keep and maintain accurate records and we discussed this with them. The registered manager told us they had strengthened the DOLS process to reduce delays in applications for DOLS and improve the review process. The provider’s record keeping omitted important information such as the date when DOLS were applied for, and the date of the required mental capacity assessment. For example, 2 DOLS had been applied for, however, confirmation of mental capacity act assessments was not documented in the records. Three further entries in the DOLS register showed mental capacity assessments had been completed, however, no DOLS applications were made. We reviewed a record documenting a best interest decision relating to the need for covert medicines. Covert medicines is considered when suitably qualified practitioners agree it is in a person’s best interests. The best interest decision was last recorded in February 2024; however, we saw the records for this decision had not been reviewed until June 2025. The medical review for this person was not completed until August 2025. This meant the provider did not ensure all applications were made in a timely way to ensure people were lawfully deprived of their human rights.

This was a further breach of Regulation 12 Safe Care and Treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

The issues highlighted above were discussed with the registered manager who told us they had taken action to ensure the process would be improved. The registered manager told us they would continue to maintain oversight of this legal requirement.

The provider had a safeguarding policy, and the registered manager was able to demonstrate how this was applied in practice. The provider’s mandatory training included safeguarding and mental capacity.

In our discussions with staff, they understood what to do to ensure people were protected from abuse. Staff said they had training on safeguarding people from abuse. One staff member said, “I would inform one of the managers straightaway.” Another told us, “If I saw any matters of concern, I would support the person and report it to the manager and record it.” The registered manager told us they were aware of their duty of candour and which agencies to report incidents to.

The provider did not always work with people or their relatives to understand and manage risks by thinking about the things they enjoyed doing. Staff provided care to meet people’s needs that was safe, however, it did not always enable people to do the things that mattered to them.

Risk assessments did not always demonstrate people, or their relatives had been involved in discussions in how to manage risk. For example, 1 person’s risk assessment noted, “Behaviour of concern care plan is in place “, however, there was no discussion with relatives as to how these behaviours might present and how it could be managed. This meant the provider did not always include people or their relatives in discussions about how to support people to minimise distress and behaviours which could impact on others. Another person’s record noted the person was previously active and enjoyed socialising in the community with support. However, their risk assessment did not include any review of the person’s current wishes to access the community, or how staff could support this. This meant the provider did not always enable people to do the things that mattered to them or include people or their representatives in discussions about how risks could be mitigated to achieve this.

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

People’s relatives told us they felt the environment was safe and well maintained. One person’s relative said, “This home is clean,” another relative said, “It’s clean and tidy, I visit weekly and it’s the same every time. It’s well looked after.” Some people’s rooms were personalised to suit their wishes, but others could be improved in this respect.

Staff received training in fire prevention and records evidenced there were regular fire drills and fire alarm tests.

We saw the home environment was safe and maintained to a good standard. It looked comfortable for people to live in, and communal areas were well laid out. People were happy and there was a friendly atmosphere in the home when we visited.

All services to the home were regularly maintained and checked for safety. We reviewed all the service’s safety certificates, such as for gas, legionella and electricity, and confirmed all the services met the required standards and had been deemed safe for use.

We saw evidence of audits and checks carried out to ensure the environment was safe. A fire risk assessment was in place so staff were able to support people appropriately in the event of an emergency. Fire equipment was regularly maintained and serviced.

Environmental audits also checked for areas requiring improvement. People had personalised evacuation plans in place, so staff knew how they needed to be supported to safely evacuate the building.

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. Staff did not always work well together to provide safe care that met people’s individual needs.

Staff received support through supervision. This included one to one meetings and team meetings. The registered manager acknowledged the frequency of these formal meetings had not always met the provider’s own policy for staff supervision. The registered manager agreed to ensure regular six to eight weekly individual supervision meetings for every staff member. They also told us they would introduce a new supervision format that set out the agenda for supervision meetings and included the direct work staff undertook with people. These measures, when fully implemented, should ensure staff have the skills, knowledge and experience to deliver effective care and support. We will monitor the progress of this work and will review it either at the next inspection or earlier if the need arises.

People and their relatives told us there were usually enough staff on duty to meet the needs of the people living in the 4 units within Langley Oaks. However, a relative told us “The staffing levels generally seem to be good. Once at the weekend though, I think it was on a Sunday, I had to stand outside for a while, in fact for over 5 minutes”. Another said “There's usually only one member of staff in [relative’s] area. Mostly the staffing levels are OK though”. We observed people having their lunch and the support they received from staff. We noted some people in the dining room needed assistance with eating and there were other people who needed support with eating in their own rooms, as they were being cared for in bed. Lunch time was also the time for people’s medicines to be administered, and a senior member of staff was doing this. Each of the 4 units had 2 support staff and 0.5 of a team leader post [the staff member who gave out medicines across 2 units]. In the discussions we had with staff, they told us there were times when more staff were needed to support people. Lunch times and night time cover were the main times when this was the case. This was evident from our observations as well.

This was a breach of Regulation 18 Staffing of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

Comments received from relatives were positive and reflected a caring and responsible attitude staff had in caring for their family members.

Access to staff training information was complex and information was not readily available to inform the registered manager what training staff had done and when they had completed it. The registered manager acknowledged this and agreed it would be helpful to have a single training register that showed the key information they needed to ensure all staff had completed all the required training.

Staff told us they received training in core areas such as safeguarding, first aid, infection control, the Mental Capacity Act, food hygiene, equality and diversity, epilepsy, autism and the safe administration of medicines.

We inspected 6 staff files which showed there were robust recruitment processes in place. Each file had a checklist to document all the stages of the recruitment process and to ensure the necessary steps had been carried out before staff were employed. These included criminal record checks, proof of identity and the right to work in the UK, declarations of fitness to work, suitable references and evidence of relevant qualifications and experience. This showed the provider had taken appropriate steps to protect people from the risks of being cared for by unsuitable staff.

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.

People’s relatives told us they thought the home was kept clean, with good cleaning schedules in place. Comments from relatives included: “People are kept safe. Staff use PPE [personal protective equipment], such as gloves and hand sanitizer and follow infection control processes,” and “The home always seems clean.”

Staff told us they received training in infection control and food hygiene, which was regularly refreshed, and which helped them maintain good practice.Staff were aware of their responsibilities to follow the policies and procedures in place to ensure good practice.

We walked around the premises and found them to be clean. Inspection of fridges and freezers demonstrated food was labelled with opening dates as required.

Appropriate cleaning schedules were in place and were carried out to help minimise the risk of infections.

The provider did not always ensure the proper and safe management of medicines.

We checked 2 clinical rooms and found medicine trollies were not secured to the wall and 1 medicines storage cabinet had a broken lock. The Deputy Manager reported this was a maintenance issue which would be rectified. This meant medicines were not securely stored in accordance with the providers policy and national guidance.

Copies of medicines policies did not have up to date information and the correct contact details for the medical out of hours service. This meant staff did not have immediate access to up-to-date information during medicines rounds. We made the provider aware of this, and the policies were updated and replaced during our assessment.

A quantity of previously discontinued liquid medicine was being stored. The deputy manager explained this was because their current process for disposal of medicines did not include liquid medicines. The provider’s medicines policy refers to the local medicines process for details of disposal. The service’s medicine policy and the local medicines process were reviewed and neither policy detailed the provision for the disposal of liquid medicines. This meant there was a gap in information to support staff to dispose of liquid medicines safely and the provider’s policy was unclear.

We noted an overdue medicine review relating to covert medicine on the electronic medication administration record (e-MAR). The deputy manager confirmed they had requested a medical review from the GP; this was followed up and had been completed.

Some people received ‘when required’ medicines. There should be an individual protocol in place for each ‘when required’ medicine, so staff can recognise when it is needed and know how it should be given. The Deputy Manager told us the protocols were held on the provider’s e-MAR system. However, there was no corresponding ‘when required’ medicines folder in the clinical room for staff, and a manager told us they were held in people’s paper care records. This meant staff with responsibility for administering medicines were solely reliant on the e-MAR record to know when this medicine should be given and how it should be given.

We did not see any written instructions from the prescribing GP when short-term or intermittent ‘when required’ medicines were prescribed. We spoke to the prescriber, and we were reassured advice regarding the administration of ‘when required’ medicines was sent via email to the provider after each medicines review. The deputy manager confirmed these were received but were not routinely recorded in the e-MAR or care records. This meant the information was not accessible to staff who had responsibility for the administration of medicines. A team leader told us they relied on the e-MAR information. As the e-MAR was completed by the deputy manager or a team leader, not the prescriber or pharmacist, and there was no corresponding ‘when required’ medicines folder which contained the information, we could not be assured the provider was complying with their own policy and was implementing all the control measures to minimise the risk of a medicines error.

We reviewed the provider’s medicines administration competency tracker. All staff had completed a medicines competency check. However, 2 staff had not completed their e-MAR e-learning and were not signed off as e-MAR proficient. This meant we could not be assured these 2 staff members, who had responsibility for medicines, understood the e-MAR system and knew how to use it and avoid gaps in medicines records.

These issues meant we could not be assured the provider was always working in line with legislation and best practice guidance to consistently make sure all control measures were optimised to ensure the proper and safe management of medicines.

This was a further breach of Regulation 12 Safe Care and Treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

Controlled drugs were stored, recorded, administered and disposed of safely. Governance and audit procedures in relation to controlled drugs were in place and effective. The provider held a weekly GP clinic and medicines reviews for people were facilitated. The provider had a robust policy and process for re-ordering and storing medicines on a monthly cycle. In both rooms inspected, air and fridge temperatures were routinely monitored and audited. Clinical rooms were clean and tidy.