Oakworth Manor 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 assessment 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.

This service scored 56 (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 clear documentation around a proactive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

There was not a consistent positive learning culture. While some incidents were investigated to understand what had gone wrong and what needed to be done about it, this was not the same for everyone. For example, one person had sustained an injury which required hospital attention. Staff involved completed a detailed reflective piece of work to learn from this. However, most incidents which occurred over the course of the month for people, such as falls, altercations and shared learning amongst the staff team, did not benefit from the same level of documentary review. We found whilst leaders did some monitoring of incidents, this was inconsistent and not robust.

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.

Staff worked in collaboration with visiting health professionals. Staff knew people well and ensured visiting professionals had a detailed handover and had access to health and social care services as they needed it. One visiting professional told us, “I have no concerns about Oakworth Manor.”

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider worked to improve people’s lives and protect their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. However, the provider did not always share concerns quickly and appropriately.

Leaders did not reliably share safeguarding concerns with CQC. While the provider appropriately shared concerns with the Local Authority when there had been an allegation of abuse or neglect, the provider did not fulfil their legal duty to also notify CQC. Although there was no impact on people using the service, the provider had a responsibility to reliably and consistently share allegations with all relevant organisations. The registered manager sent in the notifications retrospectively and gave assurances that this would not happen again in the future following guidance given.

The provider did not work well with people to understand and manage risks. However, due to staff knowledge of people’s needs, staff provided care which meet people’s needs which was safe, supportive and enabled people to do the things that mattered to them.

People were not involved or consulted on how to manage their risks. While there were risk assessments in place, we found generic or very similar statements used for different people’s risk assessments across a range of different risks. This meant people did not benefit from a risk assessment which was specific to their needs. For example, one person chose not to have a bath or shower but a daily wash. However, the person had a risk assessment in place to minimise the risk of slips and injury when bathing or showing. The content of this risk assessment was identical to that of another person. People continued to receive person-specific support and people were not negatively impacted by risk assessments not specific to their needs. This is because staff knew people and their needs and routines well.

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

Staff made sure the environment was safe for people. The service was clean, hygienic and safe for people. Housekeeping staff worked hard to maintain a good level of cleanliness. One person told us, “It’s always very clean and tidy here.” Maintenance staff completed mandatory checks, such as gas and electrical safety. Fire risk assessments were in place. While fire drills were completed, additional documentation was needed to ensure clear records were kept on who had completed the fire drill, whether it was completed within expected timescales and any learning that was needed.

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.

There were enough staff to provide safe care. There were consistent staffing levels and people told us they did not need to wait long if they needed help. Staff told us there was enough staff and a culture of working together to ensure people did not experience low staffing levels. One staff member told us, “We work well together here and cover each other’s shifts. We are never short staffed.”

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.

Staff did not always follow the provider’s infection prevention and control policy. While staff were largely observed to wear the right personal protective equipment and adhere to hand hygiene principles, this was not always consistent. Staff who administered medication did not sufficiently wash or sanitise their hands, in line with the provider’s own policy and national guidelines. This increased the risk of infection transmission. The provider put measures in place to ensure staff had access to hand sanitiser more easily. They had plans to monitor and remind staff about the importance of hand hygiene when administering medication. Provider audits did not identify the infection prevention and control improvements needed.

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.

People’s medication documentation was not always person centred and specific to their needs. While we found medication was given at the right time to the right people, medication which was needed ‘as and when required’ did not have robust or detailed guidance for staff to follow. We found people were not negatively impacted by this as staff knew people well. However, this approach was not in line with National guidelines or the providers own policy.