The 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 inspection we rated this key question requires improvement. At this assessment the rating has remained requires improvement. 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 was in breach of the legal regulations in relation to safe care and treatment and governance.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

An effective system was not fully in place to ensure lessons learned were identified, monitored and managed.

This is the 5th time the provider has failed to achieve a rating of at least good in the safe key question since 2018. The interim manager told us, “Moving forward, we can't change the past, we can only change the future…We want improvements to be embedded and sustainable.”

Staff supervision, appraisals and meetings had not been carried out as planned to share lessons learned and identify actions to help reduce the risk of reoccurrence.

The provider had formulated an action plan prior to our assessment and updated it during and following our site visits and those visits carried out by the local authority and ICB, to ensure improvements were made.

Systems were being strengthened to ensure there were safe systems, pathways and transitions prior to admission, during admission and people’s discharge from the home.

Due to the concerns identified prior to our assessment, the provider put a voluntary suspension on admissions to the home to allow improvements to be made and embedded at the home to ensure people’s safety.

An effective safeguarding system was not fully in place.

The home was in organisational safeguarding. This meant the local authority was monitoring the home and supporting them to ensure the correct procedures were in place to keep people safe.

The local authority safeguarding team told us that safeguarding allegations had not always been reported in a timely manner. The interim manager told us, “Now that the nurses know about the safeguarding process and the filling in of the forms, including measures put in place to identify the risk - now they will be accountable to submit timely safeguarding referrals.”

An effective system was not fully in place to ensure risks relating to people’s care and support were effectively assessed, recorded, monitored and managed.

Information relating to people’s nutrition and hydration, the risk of malnutrition, falls management and positional changes to reduce the risk of pressure ulcers was not always accurate. In addition, records did not reflect the actions staff were taking when one person displayed distressed reactions in relation to their personal care.

The provider had formulated an action plan prior to our assessment and updated it during and following our site visits and those visits carried out by the local authority and ICB, to ensure improvements were made.

An effective system was not fully in place to assess, monitor and manage risks relating to equipment and the environment, including the outdoor space.

The home, including the garden were not always well maintained. Window restrictors did not fully meet the guidance outlined in the Health and Safety Executive (HSE) guidance and glass was not strengthened/protected in line with legislation.

There was no maintenance person deployed at the home. Maintenance was covered by the provider’s maintenance team. Whilst the main building safety checks were carried out, planned daily and weekly checks which should have been assigned to the maintenance person had not been carried out as planned. The management team told us a new maintenance person had been recruited.

Medical equipment had not always been serviced in line with the manufacturer’s guidance. Management staff told us that this would be addressed immediately.

The provider had formulated an action plan prior to our assessment and updated it during and following our site visits and those visits carried out by the local authority and ICB, to ensure improvements were made.

An effective system was not fully in place to ensure staff were trained and supported.

Prior to our assessment, staff training, competency checks, supervision and appraisal meetings had not been carried out as planned.The provider had already identified shortfalls relating to training and staff support; training and competency checks were being organised and carried out and a new supervision and appraisal planner had been implemented.

We received mixed feedback from relatives and staff, about whether there were sufficient staff to care for people and ensure the home was clean. Some felt that more domestic staff especially at the weekend and more care staff at night would be appreciated. The interim manager told us staffing levels were under review and the number of day staff had already been increased.

Agency staff were used. People and relatives told us the permanent staff were knowledgeable about people's needs. However, they were not as positive about the skills of the agency staff.

Recruitment was ongoing. Checks were carried out before permanent staff started work at the home. We identified minor shortfalls in relation to recruitment records which we passed to management staff for their information and action. In addition, records did not always evidence that agency staff had received up to date training and were qualified for their role. The interim manager took action to address this shortfall.

The provider had formulated an action plan prior to our assessment and updated it during and following our site visits and those visits carried out by the local authority and ICB, to ensure improvements were made.

An effective infection control system was not fully in place.

Prior to our assessment, the local authority, ICB and NHS infection control practitioners raised concerns about infection control and the cleanliness of the environment. When we visited, the home was cleaner, however, areas of wood and paint work were not intact which made it difficult to keep clean. Certain areas of the home, including several people’s bedrooms were malodourous. New non-slip flooring was going to be fitted in many of the carpeted rooms to address the problem.

Records did not always evidence that an effective system was in place to ensure medicines were safely administered, stored and managed.

The management team told us action would be taken to address the shortfalls identified.