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Archived: The Oaks Nursing Home

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Inspection report

Date of Inspection: 30 April 2012
Date of Publication: 25 July 2012
Inspection Report published 25 July 2012 PDF

People should be protected from abuse and staff should respect their human rights (outcome 7)

Not met this standard

We checked that people who use this service

  • Are protected from abuse, or the risk of abuse, and their human rights are respected and upheld.

How this check was done

Our judgement

The provider was not meeting this Regulation.

People were not protected from the risk of abuse because the provider had not taken all reasonable steps to identify the possibility of abuse and prevent abuse from happening.

User experience

Most of the people who live at The Oaks Nursing Home would find it difficult to help us understand their views about the quality of the care being provided to them. We used a special tool designed to help us understand how people who have Dementia experience the care being provided to support them. We observed five people who live at the service in one of the lounges over two hours starting at 11.55am. We looked at how staff supported them with their care needs and kept them safe.

We observed a person the local authority had identified as presenting a risk of harm to themselves and others. We saw that this person's behaviour was unpredictable, saw that they were restless and therefore difficult for staff to keep track of. This was because most of the people who live at the service needed a lot of physical assistance to meet their needs. We saw this person pull food and drinks away from other people, grab hold of their arms and become verbally agitated with them. The staff did not notice these incidents occurring as they were busy assisting others and therefore took no action to address them. This meant that the person and other people living at the service were at risk of harm.

We saw a qualified member of staff respond inappropriately to this person when they would not do what the staff member wanted. We saw there was a stand off between the staff member and the person; the staff member appeared to become increasingly agitated and directive towards the person living at the service. We saw the staff member banging their hand on the table to try and get the person living at the service to do what they wanted. This was a wholly inappropriate response towards a person whose understanding and communication was affected by their illness and it was not effective in diffusing the situation. We eventually saw a member of care staff step in and quickly and effectively diffuse the situation.

We remained concerned about how staff managed restrictions to a person's freedom in respect of their access to cigarettes. The providers had told us that this person no longer had restricted access to their cigarettes and could have one when they wished. However, we observed a member of staff approach a nurse to inform them that the person was asking for one of their cigarettes. The nurse was agitated at this request and stated, "they had one 30 minutes ago, they can't have another." We saw the nurse go and tell the person this. This meant the person was still experiencing restrictions on their rights to make their own decisions.

Other evidence

The local authority and primary care trust visited the service again in April and told us they had concerns in relation to the identified person's access to their cigarettes. They considered that the poor care planning was resulting in a deprivation of liberty.

We looked at the care plan for this person. The staff had not assessed the person's capacity to make a decision about when they had a cigarette. There was no evidence that there had been any consideration as to whether it was lawful for the nurses to keep and restrict the person's cigarettes. This meant the person's rights were not being upheld.

The local authority also told us they were concerned about the inadequate monitoring of a person with a long history of physically abusing others. They told us the staff at the service were failing to follow the safeguarding plans they had put in place. Our observations confirmed this. Staff had not noticed the person's agitation and aggressive incidents taking place as they were busy with other duties. This placed the person and others at risk of harm.

We looked at the safeguarding records and saw that incidents were being referred to the safeguarding team in line with locally agreed procedures. However, we saw one incident which should have been notified to us to enable us to effectively monitor the service and it had not been.