Oak Grange

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 inspection the rating improved to good. This meant people were safe and protected from avoidable harm.

During our last inspection the provider was in breach of regulations in relation to staffing, the environment and risk assessments. We saw during this inspection, improvements had been made and the provider was no longer in breach of these regulations.

This service scored 75 (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 an engaging, proactive and positive culture of safety, based on openness and honesty and working with people to identify where areas could improve. Staff listened to concerns about safety and investigated and reported safety events. Lessons were continuously learnt to identify and embed good practice.

Staff and leaders demonstrated a positive learning culture. Incident and accident logs were well maintained, and there was clear evidence that lessons were learned from events. For example, dignity training was introduced following an incident. Staff spoke confidently about how learning was shared across the team, and people told us they felt safer as a result.

Mealtime improvements were also introduced based on feedback from people. The Head Chef attended meetings to gather feedback, people chose their preferred music, and hospitality training was provided to improve food presentation. The General Manager joined people for lunch monthly to experience mealtimes from their perspective. These changes led to improved nutrition, increased dining room attendance, and reduced food waste.

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. Transitions into and out of the service were well managed, with good communication between staff and external professionals. People told us they felt supported during changes in their care.

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. Staff had completed training and understood their responsibilities. Clear procedures were in place, and concerns were reported and acted on appropriately. People and relatives said they felt safe and knew who to speak to if they had concerns about their safety. One person told us, “I know they’d do something if I was worried.”

The provider now 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. Staff supported individuals to make informed choices and maintain independence while staying safe. Risk assessments were person-centred and reflected people’s preferences. Staff were confident in supporting people with complex healthcare needs while balancing a safety approach with autonomy and involvement.

The provider now 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 safe and well maintained. Regular audits were now carried out, including mattress checks, laundry inspections, risk assessments on portable radiators and fire safety reviews. The home was clean and free from hazards. People told us they felt comfortable and safe in their surroundings. One relative said, “It’s always spotless and feels homely.”

The provider continued to use a recognised tool to make sure there were enough qualified, skilled and experienced staff. They made sure staff received effective support, supervision and development. Recruitment was safe, and staff were deployed effectively. Call bells were answered promptly, and people said they never had to wait long for support. Staff told us they felt supported and had manageable workloads. Rotas showed consistent staffing, and contingency plans were in place. People did feedback back at certain times they felt there was not always enough staff, which we shared with the provider at the time of our inspection.

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. Infection prevention and control measures were robust. Personal Protective Equipment [PPE] was available and used correctly, and the home was clean throughout. Staff had completed relevant training and followed hygiene protocols. People told us they felt reassured by the cleanliness and staff practices. Cleaning audits were completed regularly and any issue were escalated appropriately.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. For example, staff were trained and competent, and records were accurate and complete. There were no missed doses or errors identified during the inspection. People told us they received their medicines on time and understood what they were for. Audits were carried out, and any issues were addressed promptly.