Four Oaks 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 75 (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.

Leaders reviewed incidents, safeguarding concerns and medicines events and used the learning from these to strengthen practice. Improvements following previous concerns included enhanced medicines monitoring, medicines reconciliation processes and strengthened oversight of nutritional risks. Staff were able to describe how changes had been introduced following incidents and understood their role in maintaining safer systems of care.

Learning was shared through meetings, competency assessments, supervision and ongoing communication with staff. Concerns were investigated, actions were implemented and lessons learned informed changes to practice. These improvements helped strengthen risk monitoring, medicines management and the provider’s ability to identify and respond to emerging concerns.
 

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored. They made sure there was continuity of care, including when people moved between different services.

Records reviewed demonstrated comprehensive admission assessments, medicines reconciliation processes and risk assessments were in place to support safe transitions into the service. Information from healthcare professionals and previous care settings was incorporated into care planning, helping staff understand people's needs and risks from the outset.

Staff worked with GPs, district nurses, dietitians and other healthcare professionals to respond to changing needs and ensure appropriate support was in place. Professional recommendations were reflected in care plans and staff demonstrated an understanding of how concerns such as nutritional deterioration, changes in mobility and health conditions should be escalated.

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.

The provider had systems in place to identify, report and respond to safeguarding concerns. Concerns relating to medicines, nutrition, falls and pressure care were investigated, reviewed and escalated appropriately where required. Staff understood how to recognise and raise safeguarding concerns, and leaders maintained oversight through regular review of incidents, risks and safeguarding activity. These arrangements helped ensure concerns were acted upon promptly and risks were reduced where issues were identified.

Learning from safeguarding concerns was used to strengthen risk management and improve the provider's response to identified issues. Leaders reviewed safeguarding activity, implemented actions and monitored areas of concern to help protect people from avoidable harm.

The provider had arrangements in place to support the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS). Mental capacity assessments and DoLS systems were established and supported people’s rights to make decisions wherever possible. Restrictive practices were recognised, linked to legal frameworks and subject to review. Records demonstrated oversight of DoLS applications and authorisations, helping to ensure restrictions were applied appropriately and in people's best interests where required.
 

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.

People's risks were assessed and reviewed through care plans, risk assessments and regular discussions about their care and support. Records reviewed reflected risks relating to falls, nutrition, skin integrity, medicines, mobility, swallowing difficulties and deteriorating health. Staff understood these risks and described how support was adapted when people's needs changed, helping people remain as independent as possible while managing identified risks.

Staff worked with people, their representatives and healthcare professionals to review risks and identify the support needed to maintain safety and wellbeing. Risk management arrangements were updated when concerns arose, and records demonstrated that changes in people's health, mobility and nutritional needs informed care planning and support arrangements.

The provider had strengthened risk management arrangements following previous concerns, helping to ensure risks were identified, reviewed and acted upon promptly. Restrictive interventions, including lap belts, bedrails, sensor mats and keypad-secured access, were recognised by the provider and linked to Mental Capacity Act, Best Interest and Deprivation of Liberty Safeguards processes. Records demonstrated any restrictions were subject to review and were intended to support people's safety while maintaining the least restrictive approach possible.
 

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 lived in a clean environment which was well maintained and designed to support their safety, comfort and wellbeing. We observed communal areas, lounges, dining rooms and activity spaces were clean, tidy and actively used. Flooring, furnishings and equipment were maintained to a good standard and secure access arrangements were in place throughout the home.

Environmental risks were monitored through routine checks, maintenance systems and management oversight. Laundry processes were organised appropriately; clinical areas were secure and infection prevention measures were evident throughout the service. Staff had access to personal protective equipment and waste disposal arrangements supported safe care delivery.

The provider had also taken steps to manage risks associated with the ongoing building works, including secure fencing, restricted access and alternative arrangements for communal space. Although the longer-term impact of the building works remained under review, no immediate environmental safety concerns were identified during the assessment.
 

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.

People were supported by staff who were visible, responsive and familiar with their needs. We observed people received support when required and staff demonstrated a good understanding of people's preferences, risks and care needs. Staffing arrangements were informed by a dependency assessment process, and workforce information reviewed indicated staffing levels exceeded the minimum hours identified through the provider's dependency tool. Staff told us they generally felt staffing levels were sufficient to meet people's needs and provide safe care.

The provider had experienced a period of workforce and leadership change and had responded by increasing oversight of recruitment, competency and workforce development. Evidence reviewed demonstrated the use of competency assessments, medicines reviews, training programmes and supervision arrangements were used to support staff in their roles. Staff described managers as approachable and supportive and said they were able to seek advice when required.
 

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 were supported in a clean, well-maintained environment where infection prevention and control practices formed part of everyday care. We observed communal areas, clinical rooms and support facilities to be clean, organised and free from obvious infection control concerns. Staff wore personal protective equipment appropriately and infection prevention measures were consistently evident throughout the service.

The provider had systems to support the monitoring and management of infection risks, including dedicated domestic staff, environmental checks, regular cleaning arrangements and infection prevention oversight. Laundry processes were organised appropriately, waste disposal arrangements were managed safely, and equipment was maintained in a way that supported effective infection control. Staff had access to personal protective equipment and demonstrated an understanding of their responsibilities for maintaining cleanliness and hygiene.
 

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

The provider had systems in place to support the safe ordering, storage, administration and review of medicines. Medicines were subject to regular monitoring and oversight, including medicines reconciliation, stock checks, competency assessments and audit activity. These arrangements helped ensure medicines were available when needed and managed safely.

Staff demonstrated a good understanding of medicines management and were able to describe the processes used to support safe administration, monitor risk and escalate concerns. Competency assessments, training and regular review provided assurance staff responsible for medicines management had the skills and knowledge required to carry out their roles safely and effectively.

Learning from previous medicines incidents had led to improvements in practice, including strengthened ‘patch’ monitoring arrangements, enhanced medicines reconciliation processes and increased scrutiny of higher-risk medicines. Records demonstrated medicines concerns were investigated; actions were implemented and improvements monitored through established review processes.