Oak Cottage

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 people were protected from abuse and avoidable harm. At our last assessment we rated this key question inadequate. The provider was in breach of legal regulation in relation to people’s safe care and treatment and the ways people’s medicines were managed. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm. Improvements have been embedded through strengthened systems, regular audits, and sustained staff training, ensuring changes are consistently maintained over time.

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.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to safety concerns, investigated incidents, and reported them appropriately. Lessons learned were used to continually improve and embed good practice. A quality compliance manager led regular audits to ensure documentation was accurate and reflected care delivered. Incident logs were reviewed monthly to spot trends, with findings shared in staff meetings. Staff were supported to reflect on practice, and concerns were addressed promptly. Professional partners told us they observed on-site training and saw staff independently reviewing care files. Staff were committed to learning and maintaining high standards, supported by peer shadowing, team collaboration, and reflective supervision. The provider took action to reduce the risk of closed cultures. When some individuals became socially isolated, leaders introduced engagement trackers, increased visible leadership, and adapted activity planning to promote inclusion. Regular walkarounds and a transparent, inclusive environment helped ensure people felt safe, supported, and listened to.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They ensured continuity of care, including when people moved between different services. Transitions between services were managed collaboratively with multidisciplinary teams to align with people’s long-term goals. One professional partner told us staff consistently provided timely updates during visits and by email. Each person had a hospital passport with essential health and communication details to support continuity of care. A staff member confirmed that risk assessments were regularly updated and accessible through the electronic care record system. Personal Emergency Evacuation Plans (PEEPs) were also reviewed following external feedback, including after a fire safety report, to reflect new living arrangements and needs. These practices supported consistent, proactive safety management across the service. 

The provider worked with people and healthcare partners to understand what being safe meant to them and the best ways to achieve it. Staff focused on improving people’s lives while protecting their rights to live free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. Safeguarding concerns were shared promptly and appropriately. One staff member said, “I learned how to raise concerns, who to escalate them to, and what processes to follow.” A relative told us, “I do feel [Name] is safe,” and professionals described the provider as “very responsive” when concerns were raised. Deprivation of Liberty Safeguards (DoLS) were used only, when necessary, regularly reviewed, and applied using the least restrictive approach. Staff involved people, their families, and professionals in decision-making, helping to build autonomy and trust. People were also supported to develop safety awareness and recognise signs of abuse. One person told us, “I feel safe here.” Most relatives expressed confidence in the safety provided, with comments such as, “I know [Name] is safe, and that is massive for me.” While feedback was largely positive, a few relatives did report occasional lapses in communication and escalation.

The provider worked with people to understand and manage risks holistically, delivering care that was safe, supportive, and enabled individuals to pursue what mattered to them. Detailed, person-centred risk assessments outlined clear actions, were regularly reviewed, and updated after incidents. People were actively involved in identifying and managing risks, balancing safety with choice, control, and independence. A staff member told us, “I have received training around managing challenging behaviours.,” Staff encouraged positive risk-taking, supporting people to lead fulfilling lives. For example, they helped individuals safely access the community, manage money, and build healthy relationships. People were supported to try new activities, study, and gain qualifications. Practical safety skills, like understanding personal boundaries and recognising unsafe situations, were taught to support independence. People reported feeling safe and respected in their choices, even when they involved risk. One person said, “Staff help me to be healthy and do things on my own.” 

The provider did not always identify or control environmental risks to ensure safe care. Several hazards were found, including broken radiator covers, an uneven bathroom floor, and a sharp-edged banister. These issues had not been detected through regular audits, raising concerns about maintaining a consistently safe environment. Following feedback, the provider acted promptly to address these hazards and prevent harm. Some relatives we spoke with told us environmental issues had not always been rectified in a timely way. One relative said, “The heating was not fixed for weeks.” Staff regularly discussed environmental preferences with people to support independence and wellbeing. People reported feeling physically safe in their homes, with comments like, “The place I live in is safe and the things I use work well,” and “Yes, it is great. I am happy and safe.” A relative said, “The environment is always kept up to date.”

The provider ensured there were enough qualified, skilled staff who received ongoing support and development. Recruitment followed safe, inclusive procedures, and training included trauma-informed care and positive behavioural support. One staff member said, “I have received all the appropriate training to do my job role,” highlighting regular refreshers and competency checks. Staffing levels aligned with commissioned hours, and rotas were managed to avoid gaps. Supervision was consistent, with one staff member saying, “We have supervision every six to eight weeks.” Staff were carefully matched to individuals to provide effective one-to-one support. A person told us, “The staff at Oak Cottage know me and give me the right help when I need it.” Relatives praised consistency and kindness, with one relative saying, “The staff are very nice and friendly. [Name] feels comfortable with them.” Another relative told us, “There have been changes, but only through staff being promoted, which is positive.” 

The provider did not always effectively assess or manage infection risks. We found cleanliness concerns, including unclean fridges, cupboards, and out-of-date food. Two communal bathrooms had strong odours, dirty surfaces, and overflowing clinical waste bins. Skirting boards were dusty, and a clinical waste bin had been left outside. These issues had not been identified through audits. When raised, the provider acted promptly to address them. One person said, “Cleanliness needs to improve,” and relatives gave mixed feedback. Some described poor hygiene, such as “[Name]’s shower is filthy,” and “The oven was left dirty,” while others felt the home was clean. A recent food hygiene inspection rated the kitchen as good (5). Staff received infection control training during induction and ongoing e-learning. They understood their responsibilities, including ensuring PPE supplies, cleaning high-touch surfaces, and wearing new PPE for each person. While improvements had been made, more consistent monitoring was needed to maintain hygiene standards. 

The provider ensured medicines and treatments were safe and tailored to people’s needs, capacities, and preferences. Staff involved people in planning and informed them promptly about any changes. Medication records were kept current and regularly reviewed to reflect changing needs. Only staff who completed medication training were authorised to administer medicines. People were actively involved in decisions about their medicines. Risk assessments were conducted collaboratively to promote independence wherever possible. For example, one person participated in assessments and regular reviews to determine the right level of support, with their preferences clearly documented in their care plan. Where appropriate, people were supported to self-medicate, encouraging autonomy while maintaining safety through monitoring and assistance. Care plans clearly outlined the specific support each person required with their medicines, ensuring the right support was provided.