Oakham 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 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 62 (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 a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Accidents and incidents, including falls and the development of wounds or pressure ulcers, were routinely analysed to identify patterns and emerging risks. The provider held regular governance meetings where incidents and safeguarding concerns were reviewed, ensuring leaders maintained oversight of safety issues. Learning from internal investigations was clearly identified and shared with staff, promoting reflection and supporting changes to practice. This approach helped reduce the likelihood of incidents recurring and contributed to a culture where safety was openly discussed and continuously improved.

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 experienced safe and well‑planned transitions into the service. Before a person moved in, the provider completed a comprehensive assessment of their needs to ensure the service had the skills, staffing and resources to meet them safely. This process included gathering information from professionals, families and previous placements where appropriate. Any equipment required to support the person’s health, mobility or safety was arranged and in place prior to admission.

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.

People and their relatives told us people received safe care and treatment. A person said, “I feel very safe and secure and have complete confidence in them all. It’s my first care home and I’ve never felt unhappy.”

Staff received safeguarding training and demonstrated a clear understanding of their responsibilities. Staff were able to explain how they would raise concerns. A staff member told us,“If I suspect abuse, I would report immediately to the nurse in charge or our safeguarding lead and follow the whistleblowing policy if necessary.”

People can only have their freedom restricted for care and treatment if there is a legal process in place. In care homes, this is managed through the Deprivation of Liberty Safeguards (DoLS), part of the Mental Capacity Act 2005. The provider regularly checked and monitored these safeguards. Each person’s care plan included details about their mental capacity and any DoLS in place, explaining what this meant for their support.

The provider worked with people to understand and manage risks by thinking holistically. However, 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.

Risk assessments addressed all aspects of people’s care and support needs. Risks to people’s health and wellbeing had been identified, assessed and planned to support them to stay safe. Staff knew people well and understood the risks posed to people. Records showed staff mostly followed the assessments in place to keep people safe. However, we identified some concerns in relation to protecting people from the risk of developing pressure injuries. For example, we found 2 people at high risk of developing pressure injuries, their repositioning records contained gaps and were not completed in line with the guidance set out in their care plans. This meant staff could not demonstrate people were being repositioned in line with best practice guidance to prevent pressure damage or deterioration of existing wounds. Although some people had existing wounds, records did not indicate these had deteriorated or resulted in adverse impact at the time of inspection.

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

Robust systems were in place to ensure the home and its equipment were properly maintained and serviced. Regular checks were carried out, including scheduled servicing and safety inspections such as electrical compliance testing and fire risk assessments.

The provider undertook comprehensive risk assessments of the premises and implemented measures to ensure the safety of people, staff, and visitors. Individual Personal Emergency Evacuation Plans (PEEPs) were in place for each person, detailing the specific procedures required to support their safe evacuation in the event of an emergency.

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.

Staff were recruited safely and had robust pre-employment checks carried out before starting work. We observed there were enough staff available to support people safely on both days of our site visits. New staff received an induction when they started work which provided them with the training needed. Staff told us this was regularly refreshed. Training was provided in a range of areas including specialist training for behaviour support, sepsis, diabetes and dementia. A staff member told us “We get both physical and online [training]. It’s a lot and it’s good here as we keep up with our training. If you require any additional training [the managers] will book it for you. We have external bodies as well so not just internal.”

There was some agency staff being used to cover gaps in staffing numbers at short notice. The registered manager told us they used the same agency staff who knew people well.

We received mixed feedback regarding staffing levels. One person told us, “I’d say there was enough staff, from what I notice.” A relative said, “There is always a good number of staff around, it’s not difficult to get someone’s attention.” However, some people told us they experienced delays in getting the support they needed. One person said, “They [staff] don’t answer the bell, or will come and turn it off and say they’ll be back, and it’ll be another 30 minutes.” We fed these concerns back to the provider, who took action immediately by seeking feedback on how promptly staff were responding to call bells and providing support. They shared with us the actions they would be taking to address the concerns found following the 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.

Staff had received training in infection prevention control. There was personal protective equipment (PPE) available for staff to use when needed. The provider employed dedicated housekeeping staff who had systems in place to maintain cleanliness at the service.The home was clean and tidy throughout. One person said, “It’s spotless here, I’d hate to be a bug! The laundry does an excellent service.”

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

Records related to the management of medicines were not always detailed or maintained to evidence safe administration. PRN (when required) medicines were not consistently supported by adequate instructions, which could limit staff’s ability to administer these medicines safely and consistently. Some people required fluids to be thickened to reduce the risk of choking. However, thickener use was not consistently documented when administered and records did not provide assurance that thickeners were being used correctly. We also found that body maps and patch monitoring records were not consistently in place, which limited assurance that patches were being applied correctly and monitored safely. There were inconsistencies in the paperwork of prescribed creams as topical medicines administration records (TMARs) were not always completed, so we were not assured creams were being applied as prescribed.

During the observation of the Medication Administration Records (MARs), we found inconsistencies across records, including discrepancies in documentation and timing of medicines. This meant it was not always clear that medicines had been administered fully in line with prescribed instructions, increasing the risk of people receiving medicines incorrectly and experiencing harm.

Temperature monitoring was being completed and recorded in areas where medicines were stored. However, at the time of inspection, we found that fridge temperatures were frequently recorded above the recommended range and there was no documented action or follow‑up to demonstrate that risks to medicines stored in the fridge had been mitigated. This could affect the efficacy of the medicines stored there.

Medicines were supplied and delivered by their nominated pharmacy, good communication and arrangements were in place for obtaining advice during out‑of‑hours periods. A clear process was in place for ordering medicines in a timely way to ensure medicines were available for people using the service. Staff demonstrated good oversight of medicines management, including ordering and booking in medicines, monitoring low stock levels, and responding appropriately to out‑of‑stock medicines to reduce the risk of missed doses.

Medicines, including controlled drugs, were stored securely and recorded correctly.

Following the inspection, we met with the provider to discuss the findings and the progress made since our visit. The provider gave assurances that most required actions had been completed, with the remaining areas showing improvement but requiring additional time to fully embed. The provider also outlined steps being taken to strengthen staff training and refine internal processes to reduce the risk of similar issues reoccurring.