Oaktree Homecare Services Limited

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.

The provider was in breach of the legal regulation in relation to providing safe care and treatment to people. There was a potential risk some people could be harmed. The provider was also previously in breach of this legal regulation. Improvements were not found at this assessment.

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This service scored 53 (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 openness, curiosity 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 registered manager and provider did not investigate when people telephoned to ask for a named member of staff to not return to provide care and support to them. This meant for example, a practice or knowledge issue about the member of staff which could be rectified through further support and training for that member of staff, or potential safeguarding matter which may require further investigation and outside input from the local authority could be missed.

When an investigation did take place following an allegation by a person, no formal process was followed to promote lessons to be learnt. For example, there was no documented evidence how or if this ‘investigation’ had taken place.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety.

When a person’s needs had changed, the registered manager and provider did not complete a full review of their care and consider speaking with health and social care professionals. There were also concerns with how this person’s relatives were supporting this person, but the registered manager did not review the situation to promote this person’s safety and well-being.

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. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

A potential safeguarding concern that was likely an unintentional consequence of trying to keep a person safe had not been addressed. However, the understanding of this by staff and the registered manager was not sufficient to identify the potential issues of possible harm and restriction. The registered manager did not take appropriate actions to contact the local authority safeguarding team. Following our feedback, they did this. We also spoke with the local authority about this.

When we spoke with staff, most did not have an understanding that people could experience potential abuse from others. This was a risk as they were not open to this possibility, and therefore they may miss a sign this was actually happening to a person.

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.

Risk assessments did not always fully explore risks which people lived with. As a result, staff were not fully guided about how to manage and understand the risks people faced or identify signs of the risks getting worse. There were missed opportunities to involve people in the exploration of these risks to help everyone to be safe. We found examples of this when people were at risk of choking, risk of falls, and could become agitated and aggressive towards staff.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The registered manager and provider completed environmental risk assessments of people’s homes on a routine basis. However, the risks which people experienced were not fully explored and environmental factors considered alongside these risks. This meant the registered manager, provider, and staff did not always have a clear understanding of the actual risks. When some people needed to use equipment to help them move about, their home environment was not considered to assess the risks and challenges of using equipment in their home.

People told us they generally received care visits at times they were OK with, and they now saw a regular group of staff or a regular individual member of staff. However, people also told us they helped their regular staff by letting them leave early so they could travel to their next person and reach them on time, as their work rota did not allow enough travel time. When we analysed the service’s care visit data, we found 3 people saw a lot of different staff and one member of staff had no travel time. Further work was needed by management to ensure the delivery of staff was effective. The registered manager and provider were not analysing their care visit data, they were relying on the electronic log in and out system to tell them if there was an issue. There were patterns of staff practice and issues with care deployment which they were not seeing, because they were not looking at the data themselves or asking people and staff questions about this.

Staff received training in aspects of the care they provided. Staff spoke well of the supervision, team meetings, and the training the provider organised. However, staff could not tell us what was good about the training they had received and how it benefited their work. The registered manager did complete some competency checks on staff practice, but these did not assess staff knowledge and their understanding of the risks which individuals faced and test their knowledge of other areas of their work.

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.

People’s relatives spoke well of the staff’s hygiene practices and staff’s use of personal protective equipment. Staff talked us through how they used safe infection protection control practices to keep everyone safe.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

When we reviewed the electronic medicine administration records (MAR), we found there were gaps when staff had not signed to say if a person had received their medicines. These records had been audited by the provider, but these gaps were not identified, explored, and clarified. The registered manager believed these gaps were due to people being away from home those days, but this was not confirmed by them when the audit was completed. The medicine electronic system should not allow staff to log onto their next care visit if a medicine had not been signed for. However, the registered manager and provider had trusted the system without confirming if people had or had not received their medicines in these instances and documented this. There was a risk people had not always received their medicines and the system was faulty.

People did not have effective medicine care plans, even when they had complications with their medicine regimes, such as not eating before or after certain medicines. A person had a ‘as required medicine’ (PRN) but this was not explored in their care plan, they did not have a PRN protocol. The registered manager had not identified a potential issue with the frequency of this person having this medicine when this person’s medicine records were audited.