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 that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service continued to be in breach of legal regulation in relation to keeping people safe from harm, safe care and treatment and a lack of training for staff to support people appropriately. We identified a new breach relating to how the environment meets people’s needs.

This service scored 38 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The provider did not always have a proactive and positive culture of safety based on openness and honesty.

The registered manager could show us some examples of where there had been some learning around incidents that occurred in the home. However, lessons could not be embedded in daily practise as incidents we reviewed had not been escalated or discussed with staff. The culture of the home did not have a strong learning culture. Incidents and accidents were recorded, but there was a lack of evidence of lessons learnt to prevent recurrence. Staff spoken with were unable to tell us about the lessons learned arising from some of the incidents we identified. Staff knew of the incident but said they had not had those discussions to fully understand the risks and how to learn from the incident.

Audits did not fully capture the ongoing improvements required. The registered manager did not look at incidents, safeguarding concerns, indicators of risks to identify trends or themes to look at wider risks to people. Therefore, staff did not have a full picture of to discuss lessons to be learned and where practise could improve.

The provider had not adequately invested in its management team to ensure the service was managed effectively and safely. Managers had not received appropriate training in incident management or in promoting a culture of candour among staff, which limited the embedding of good practice and hindered improvements to the quality-of-care people received.

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.

People were supported to see health care professionals and referrals to those specialists were made promptly and when needed. This included referrals to the community mental health team, speech and language therapist, dietician and community nursing services. One person told us they had moved to Oak Cottage from another service and said the support they received across all the services involved had been exceptional. Although the care records were not always updated to reflect these positive changes for this person.

People received care by staff who supported them with attendance at medical appointments for their mental and physical health care to be monitored. Staff knew people well and were clearly passionate about providing them with safe care.

A visiting health professional worked closely with staff in the home. They told us that staff gave them the information they needed in a timely way which was up to date and ensured their treatment plan was followed. They said they felt staff would report any changes to people’s conditions promptly to the relevant health professional.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

At our last inspection in November 2024, we found systems were not effectively managed to identify potential instances of abuse. We also found incidents of potential abuse had not been referred to the local safeguarding authority. At this inspection we found improvements had not been made and the provider remained in breach of regulations relating to keeping people safe from harm.

People and relatives told us they felt safe with the care provided. One person said, “The other residents are very kind to me, I feel very safe living here, I can’t think of a time when I haven’t, and I have lived here for quite a while.” We saw that people were comfortable with staff and that interactions were warm, kind and sensitive between them. Staff were aware of one staff member described this to us and said, “To me it means protecting the residents, human rights, their health and wellbeing against abuse harm and neglect.”

However, we found that safeguarding concerns continued to not be reported to the local authority when people were at risk of harm. 2 safeguarding concerns had been reported to the local authority in the 11 months prior to this inspection by the registered manager. We identified a further 7 separate instances where people placed themselves at risk or had harmed others not reported as required. One of these instances led to a further occurrence where the person involved was again at risk of harm. The initial incident had not been investigated thoroughly to implement strategies to keep them safe and prevent recurrence.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

At our last inspection in November 2024, we found systems were not effectively managed to identify potential instances of abuse. We also found incidents of potential abuse had not been referred to the local safeguarding authority. At this inspection we found improvements had not been made and the provider remained in breach of regulations relating to involving people to manage their care safely.

At this inspection people told us that staff knew them well and discussed their care with them. Through our discussions with staff we found they did know how to support people safely, and what their current support needs were. People had not experienced harm because of a lack of involvement, or reviews when needed, but the systems operated placed them at risk of unsafe or inappropriate care.

The management team responsible for developing care plans had not ensured all known risks had been assessed to ensure people remained safe. For example, one person lives with dementia and regularly refused personal care. They can become agitated and lashed out at staff if they did not want support. A risk assessment for this had not been completed, and a care plan to support this person with a positive and pro-active approach had not been developed or discussed with staff. Managers had referred this person for a medication review to assist with the refusal but had not considered alternative approaches. This constant refusal had then continued.

Overall, there was a lack of information available to staff regarding how to effectively identify a change or example, where people with diabetes or heart difficulties may present when experiencing poor health. Managers who completed assessments of people’s care had not had the training to enable them to sufficiently do so.

At this inspection, 46 [62%] of risk assessments were not in place and 58 [68%] of subsequent care reviews for those that had been completed to safely manage the risk were not completed.

Staff told us that they were called ‘key workers’ meaning they would review peoples care with them and senior staff. However, staff said they were not involved in developing or reviewing care and that care records did not reflect people’s current needs.

One visiting professional who worked closely with the home said, “My issue is with the care plans; it has taken them months to start to use the electronic system and even when they have done them they still aren’t describing how to provide the support the clients need.”

We discussed this with the provider who acknowledged the lack of care plans and risk assessments. They told us they were changing to a digital care planning system and had had trouble with this; however, this change had been ongoing for over six months. The provider during this inspection took action to develop the key worker role to ensure staff would be part of care reviews which would help ensure care records would be reflective and robust

The provider detected and controlled potential health and safety risks in the care environment. However, they continued to fail to ensure the environment was well maintained and adapted to the needs of people living there. Facilities and technology supported the delivery of safe care.

The safety of the premises was monitored, and staff regularly carried out fire safety checks. People had evacuation plans in place to leave the building safely in the event of an emergency. A fire risk assessment was in the process of being updated and the management team were working with the fire officer to complete those actions arising. Equipment needed to support people with their care needs or mobility was in place to manage risks such as sensor mats, pressure relieving equipment and walking frames. Equipment was regularly checked and serviced when and as required.

People’s bedrooms were personalised which reflected their personality. People had free, unrestricted access to outside spaces and a lounge, dining and communal area to facilitate visits.

However, at our last inspection in November 2023 we asked the provider to address the condition and adaptation needs of the home to meet people’s specific needs, for example those people living with dementia or those who could become disorientated. At our last inspection we found some areas were tired and in need of repair and the environment did not support people positively to live within the home and find their way around. At this inspection, some refurbishment had been completed following actions from the fire brigades visit earlier in the year. However, those works left gaps around doorframes, unpainted doors and walls and continued wear and tear to walls and woodwork.

The general environment continued to not be adapted to meet the needs of people the service is registered to provide accommodation and personal care to. The provider is registered for services for people with dementia and sensory impairments. However, adaptations such as using induction loops, textphones, videophones for communication or anti-glare lighting, colour contrasting to depict different areas of the home, tactile symbols and signage or padded protection over hazards or obstructions where such features cannot be removed had not been considered or installed. This continued to be an area for improvement from our last inspection, so the provider is in breach of regulations relating to the suitability of their premises.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

At our previous inspection in November 2023, we imposed a breach of regulation as the provider had not ensured staff were sufficiently trained. At this inspection, the provider had not made the required improvements and remained in breach of this regulation.

During this inspection, we reviewed the training records of the 25 staff employed, as well as the registered manager and three managers. The records showed that staff had not completed training at an appropriate level for their roles. Although key mandatory training had been assigned according to their roles, no staff member had completed all required training. Examples of this were thirty two percent completed mental capacity awareness and food hygiene. Thirty six percent completed infection control, with sixteen percent completing falls prevention and falls response. People were supported to manage health conditions such as diabetes, however, only fifty two percent of staff completed diabetes training. In this case, half the staff team had not received training to help them identify when a person is experiencing a hyperglycaemia [an excess of glucose in the bloodstream, often associated with diabetes] or hypoglycaemia [deficiency of glucose in the bloodstream]. Where people required additional support with their care needs, for example people living with Dementia / Parkinsons or needing end of life support, staff had not received training for those needs and additional areas such as pressure wounds, skin integrity and sepsis awareness. This overall lack of training in these and other core areas placed people at risk of unsafe or inappropriate care.

We found some staff had however been provided with higher level training. Staff had received training to act as a champion in a particular area. These are workers who have specialised knowledge in a specific area and act as a resource for colleagues. 4 staff as dementia champions, 2 staff as medication and mental health champions and 1 staff member for moving and handling and engagement. Staff told us and the registered manager agreed that the champions role is to promote best practices and help implement new ideas or changes within a care setting, such as in areas like dementia care. We spoke with staff about their ability to share best practise among their colleagues, however, those champions spoken with said they were not given an opportunity to review practise, observe staff engagement, be part of care reviews within their specialism or share lessons learned from incidents. This meant that although some staff had achieved a higher level of understanding, the registered manager did not ensure this was part of the culture within the service. People therefore continued to be at risk of receiving unsafe or inappropriate care from staff who did not have sufficient training.

We looked at the training for the registered manager and 3 other managers employed. No staff member, either champion or manager had received training to support them to provide supervision, coaching skills to staff, higher level risk assessment, mental capacity assessment, incident investigation, safeguarding for managers and governance. This lack of higher-level training for those staff led to improvements being identified in areas of incident response, lessons learned, risk and care reviews, mental capacity assessments and appropriate best interest decisions and overall monitoring and compliance of the quality of care provided.

We observed, and some people told us, they did not feel there were enough staff to provide person-centred care to people when they requested this. People told us they experienced delays sometimes when summoning assistance. They said that staff were busy all the time and had little time to spend with people away from their caring tasks. One person said, “I see the staff about the place, but they are usually run off their feet. Look here, there isn’t anyone in here with us this morning is there and hasn’t been for some time. They must do the cooking, clearing up, help us, do the sheets and washing and all the other things. I think it must be a hard day for them.”

Staff told us they were busy carrying out their caring role, but also preparing breakfast, evening meals and laundry among other tasks. This they said impacted on their ability to provide people with the person-centred care they wanted. We discussed this with the registered manager who acknowledged the feedback and changed the sleep in night shift to a waking night and re-distributed the additional tasks. [Waking night staff are carers who stay awake all night to provide continuous care to individuals needing overnight care. Sleep in carers sleep during the shift but are onsite so that they can quickly respond if they’re needed during the night.]. Managers were redeployed into the care home from the office to be able to provide support and leadership on the floors. Although we did not find people suffered harm because of the deployment, people’s overall experience could be better managed.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We have referenced the deficiencies in the environment in the safe environments section of the report, however, the damage to the walls presented a risk to harbouring infections and impedes thoroughly cleaning of the communal areas of the home. People said the home was clean and were happy with the cleanliness of the service. Aside from the issues found in the communal areas, we saw people's bedrooms were clean, pleasantly decorated and personalised to everyone. Care staff regularly prepared people breakfast however of the twenty-five staff employed, thirty two percent had completed their food hygiene training. For the remaining sixty eight percent, the registered manager could not be assured staff prepared meals safely to minimise the risks of unsafe meal preparation or storage.

Although a cleaning schedule was in place, some areas of the home we saw needed further attention. For example, the white banister leading to the first floor was blackened from use. One of the toilets we looked in was stained with heavy limescale in the toilet and the pipes scaled with limescale and discoloured and the floor around the toilet needing cleaning.

Staff used personal protective equipment [PPE] when providing personal care and confirmed they had received training to manage infections and cleanliness. Staff said they always had sufficient stock of PPE. Policies were in place to manage outbreaks effectively and in line with Government guidance

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.

At our last inspection in November 2024 people’s medicines were not safely managed. At this inspection enough improvement had been made, and the provider is no longer in breach.

People received their medicines as the prescriber intended by staff who had received training to safely do so. Improvements had been made, including the implementation of PRN (medicines as required) protocols, although these lacked sufficient detail to inform staff of when to administer a medicine and how to monitor people for improvement or side effects. We also saw some PRN records were copied and pasted, therefore not relevant to the person intended. Care records showed that homely remedies medicines had not all been checked by a GP to ensure they were safe to give in conjunction with prescribed medicines. A homely remedy is a medicine used to treat minor ailments. They are purchased over the counter and do not need to be prescribed.

Improvements were needed to ensure the temperature of the medicines room was within safe levels. We found the staff had opened the window with the tumble dryer next to it, which meant hot air was blown into the medicines room. This increased the overall temperature of the room and fridge and meant medicines were not always stored within safe levels. The registered manager took immediate action to remedy this, installing an air conditioning unit and securing the window.

The staff worked closely with the local GP practise, and with local professionals such as the specialist mental health team. We saw reviews of medicines were carried out promptly. Where medicines were prescribed to manage behaviours, these were regularly reviewed to avoid the risk of over prescribing.