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Inspection Summary

Overall summary & rating


Updated 15 January 2020

About the service

Oak farm is a Nursing home and rehabilitation support unit providing accommodation, personal and nursing care to up to 32 people living with a brain injury, under the age of 65. At the time of the inspection the service was fully occupied supporting 32 people.

People’s experience of using this service and what we found

Risks to people’s safety had not been adequately assessed or reviewed. We identified that equipment was in use that should have been removed from service due to safety issues. Staff did not ensure pressure relieving equipment was used safely and in accordance with the assessed settings.

People were not protected in a safe environment. The premises were unclean in places and not maintained to a standard which ensured people were safe. We identified risks in the environment which had not been recognised or addressed by staff or the management.

The management of medicines had improved since our last inspection, but we found improvements were still required in record keeping, ensuring safe application of pain-relieving patches and administration of controlled drugs. Improvements needed to be made to the providers recruitment processes to ensure suitable staff were employed to work at the service.

We identified insufficient monitoring and oversight of people’s nutrition and body weight, including where people used a feeding tube and did not eat orally. Action was not always taken when peoples body weight began to decline. Improvements had been made to staff training and supervision of their practice. People felt staff were competent.

We were not assured that people were always supported to have maximum choice and control of their lives and that staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported did not support best practice.

People told us the staff were caring and kind towards them. However, staff did not always promote people’s dignity to ensure their right to privacy was upheld. People were not always involved in all aspects of their care planning, we found that goals had been identified in care records for people without their input.

Care records did not always provide sufficient detail to guide staff on how to look after people and were not updated when peoples needs changed. Regular reviews of care records to ensure they remain relevant were missed. Staff understood how to support people in line with their communication needs. People had the opportunity to be involved in activities within the service and local community. People understood how to complain and told us concerns had been acted on. Plans were in place to give staff guidance on how people wished to be supported at the end of their life

There was a lack of clear governance in the service and the provider did not have effective systems in place to consistently assess, monitor and improve the quality of care. This meant poor care was not identified and rectified by the provider. Our two previous inspections have rated the service as Requires Improvement and the service is now rated Inadequate. We are therefore concerned about the overall governance of the service.

Rating at last inspection

The last rating for this service was requires improvement (published 11 October 2018) and there were multiple breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

We found concerns during this inspection and there were repeated as well as new breaches of regulations. We rated the key questions safe and well led as inadequate. The key questions Effective, Caring and Responsive were rated Requires Improvement. The overall rating is Inadequate. This is based on the findings at this inspection. This is the third consecutive inspection where the provider has faile

Inspection areas



Updated 15 January 2020

The service was not safe.

Details are in our safe findings below.


Requires improvement

Updated 15 January 2020

The service was not always effective.

Details are in our effective findings below.


Requires improvement

Updated 15 January 2020

The service was not always caring.

Details are in our caring findings below.


Requires improvement

Updated 15 January 2020

The service was not always responsive.

Details are in our responsive findings below.



Updated 15 January 2020

The service was not well-led.

Details are in our well-Led findings below.