Oakley Lodge

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 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 learned, shared and used to continually identify improvements and embed good practice.

Leaders promoted a learning culture where incidents, complaints, feedback and day-to-day experiences were reviewed to identify learning and drive improvement. Staff were encouraged to reflect on practice, share ideas and contribute to service development. There were examples of learning leading directly to improved outcomes for people. For example, reviewing incidents alongside health information helped staff better understand the causes of 1 person's distress and adapt their support accordingly. Following a separate incident, lessons learned were discussed with staff and the person was referred to specialist services. Support arrangements were subsequently reviewed and updated to reduce future risk.

Overall, staff feedback demonstrated that learning was shared through debriefs, staff meetings, reviews of incidents and support strategies, and supervision, with staff reporting they felt able to approach leaders for support and guidance. The provider also received safety alerts from government bodies, the local authority and CQC, which were used to identify emerging risks, themes and trends and support appropriate action to mitigate risks.

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.

Leaders described robust referral, assessment and transition processes to ensure people's needs could be safely met and new admissions were compatible with others living at the service. People and relatives were involved in planning transitions, and information was shared with relevant professionals to support continuity of care. Leaders also described arrangements to maintain continuity during hospital admissions, including the use of hospital passports, plans to reduce avoidable hospital admissions and staff support where required.

One person spoke positively about their transition from living at home to the service. Staff and leaders described how the move was carefully planned and adapted to reflect the person's needs and preferences. Staff reported positive outcomes following the move, including increased independence and wellbeing.

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 consistently told us they felt safe living at the service and knew which staff members they could speak to if they were worried, upset or concerned. Staff demonstrated a good understanding of safeguarding responsibilities and were confident in recognising and reporting concerns. Overall, staff described an open culture where concerns could be raised with managers and felt action would be taken in response.

Leaders promoted safe, respectful and person-centred approaches to support, helping staff understand how to reduce risks while respecting people's rights and preferences. Safeguarding concerns were reviewed and assessed appropriately, with leaders working alongside partner agencies where required. Leaders demonstrated a commitment to learning and improvement, using feedback, review processes and incident learning to strengthen oversight, communication and partnership working, helping to promote people's safety and wellbeing.

Leaders demonstrated an understanding of the legal framework relating to restrictive practice and Deprivation of Liberty Safeguards (DoLS). Where people were subject to restrictions, appropriate legal authorisation had been sought to support people's safety whilst protecting their rights.

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 were supported to understand risks in ways they could understand and remained involved in decisions about their lives, including activities, community access and daily routines. Staff used personalised approaches, including visual timetables and structured routines, to support people's understanding, reduce anxiety and promote informed choice.

Leaders promoted a positive risk-taking culture and encouraged staff to focus on how people could safely pursue opportunities that were important to them. Staff and leaders described supporting people to try new experiences and achieve personal goals while ensuring risks were assessed and managed appropriately. Restrictions were reviewed regularly and reduced where possible, helping people maintain their independence, choice and control.

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

The environment was accessible and adapted to support people with a range of needs. This included wheelchair-accessible accommodation, adapted facilities, accessible outdoor areas and communal spaces. Staff understood how to report environmental concerns and told us maintenance issues were addressed promptly.

Leaders maintained oversight of environmental safety through regular checks, audits and monitoring processes. Records demonstrated appropriate management of areas including fire safety, legionella prevention and maintenance. Leaders were aware of environmental issues requiring attention and had systems in place to ensure these were addressed appropriately.

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 told us staff were available when needed, knew them well and understood their individual support needs. We observed sufficient staffing levels to support people safely and enable participation in daily activities. Staff received appropriate training, supervision and support, and safe recruitment processes were followed.

Leaders maintained oversight of staffing levels and skill mix, adjusting staffing arrangements in response to changing needs and risks.

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 told us they were supported to keep their personal spaces and the home clean. We observed the home was clean, tidy and well maintained.

Staff understood their responsibilities for infection prevention and control and told us cleaning materials and personal protective equipment were available when needed. Leaders maintained oversight through audits, cleaning schedules and monitoring systems.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

We identified concerns relating to some medicine’s records and documentation. Information about people's medicines was not always recorded clearly or consistently, and records relating to some 'as required' medicines were not always completed in full. The provider had already identified some of these issues and was acting to improve recording practices, guidance and staff oversight.

Whilst there was no evidence people had come to harm, these shortfalls increased the risk of people not always receiving consistent support with their medicines. Leaders responded promptly to our findings and took further action to strengthen medicines systems and recording practices. However, more time was needed to ensure improvements were fully embedded and sustained.

Medicines were stored safely and stock balances were accurate. People and relatives were positive about the support they received with medicines, and staff were able to describe how they supported people with their medicines and health needs.