Oak House

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. We identified an ongoing breach of the Safe care and treatment regulation.

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 59 (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 on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

Staff were able to explain how they would respond to any concerns around people’s welfare or safety. The registered manager maintained a record of any falls or adverse incidents reported by staff within the service. However, there was no evident system in place to ensure learning from these events was shared within the staff team, which would aid in reducing the risk of the incident happening again.

The provider understood their responsibilities under Duty of Candour, and relatives confirmed they were kept informed of any incidents. We saw this formed part of the provider’s Service Improvement Plan.

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.

There was a procedure for staff to follow before people were admitted to the home. This included a pre-admission assessment to establish a person’s needs. Care records showed where healthcare partners had been involved in people’s care and treatment to improve outcomes.

The provider had a process in place to ensure continuity of care. For example, if a person was admitted into hospital, the relevant and key information the hospital staff may need could go with them.

The provider worked with people and healthcare partners when safeguarding matters were identified. Staff were able to explain how they wanted to ensure people were safe within the service. The provider shared concerns with relevant organisations appropriately. There were provider level systems that ensured data shared and requested by the local authority was captured.

There were systems in place to ensure people were protected from the risk of harm, abuse or discrimination. This was not evident at our previous assessment, and the provider was in breach of the safeguarding regulation. Sufficient improvements had been made, and the provider was no longer in breach of regulation. We saw safeguarding concerns had been raised where appropriate with the local authority.

Staff were able to clearly describe to us how they would identify potential abuse and what action they would take to escalate this appropriately. No concerns were raised by people or their relatives about the care and support they received from staff.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service.

Whilst we found no impact to people, we identified the provider did not have consistent systems and processes in place to monitor approved and pending DoLS applications to ensure their expiration date was monitored and conditions were followed. The registered manager completed a tracker following the assessment that showed where DoLS had been approved and others that were pending with the relevant local authority.

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, supportive and enabled people to do the things that mattered to them.

Care plans and risk assessments included the guidance staff needed to help keep people safe.However, some risk assessments had not always been completed in a timely manner or ensured all risks had been assessed. We saw examples where people who had been discharged from hospital had not had their specific medical needs assessed. Other care records showed a significant delay between admission and completion of risk assessments or that assessments for matters such as falls had not been completed accurately.

Whilst the assessment had not identified any impact to people using the service, the failure to undertake timely and accurate risk assessments placed people at risk of harm. This contributed to a breach of the safe care and treatment regulation.

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.

Equipment such as lifts, hoists and those related to gas safety had been inspected in line with requirements. Each month, safety checks were completed by a dedicated member of staff on equipment used to support people, such as specialist beds, call bell systems, wheelchairs and walking aids. Records showed legally required checks of mobility and lifting equipment had been completed.

We found fire safety measures needed to be improved. There were personal evacuation plans for people in place. However, key information required in the event of a fire was not available for staff or the fire service. For example, there was no information aligned with the requirements of the Fire Safety Order 2005, such as floor plans. This publication also highlights the requirement of an emergency plan that had not been made readily available for staff. This placed people at risk and contributed to a breach of the safe care and treatment regulation.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff told us they worked together well to provide safe care that met people’s individual needs, and our observations supported this.

People, their relatives and staff told us there were enough staff on duty to meet people’s needs. Rotas were planned in advance, and the registered manager told us they were based on occupancy levels and needs. A staff member commented, “Yes, the staffing levels are well planned to meet residents’ needs safely and effectively. Everyone on shift understands their responsibilities.”

When staff started work at the service, they completed a period of induction. This included a period of shadowing where they worked with more senior staff to understand the day-to-day running of the home and meet with people whom they would be supporting. Staff completed an induction booklet, which was signed by them and a senior staff member as they completed each section. This included training, policies and observations of staff in practice, for example infection control and safe moving and handling.

The provider had appropriate training and continual staff support in place. Staff were positive about their training and told us they received ongoing individual and group supervision together with an appraisal. We saw records evidencing staff training. Staff were recruited safely with appropriate checks taking place to ensure their suitability to work with vulnerable adults.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading.

Staff were trained in infection prevention and control. Staff understood when and why they should use personal protective equipment (PPE) and we saw this was readily available throughout the building. No concerns were raised by people’s relatives or healthcare professionals in relation to the cleanliness of the environment.

The environment was clean, and there were no malodours; housekeeping staff were on duty. The registered manager and provider used auditing systems and processes to monitor the cleanliness of the service.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people and their relatives in planning where appropriate, including when changes happened.

At our last assessment, the provider did not have effective systems and processes to manage medicines safely and was in breach of this part of the safe care and treatment regulation. At this assessment, we found the provider was no longer in breach of this part of the regulation, but improvements could still be made.

Medicines were mostly stored, administered, recorded and disposed of safely. Processes were in place to ensure people received their medicines in line with their prescriptions. Regular stock balance checks were carried out.

Some people were prescribed additional medicines on a ‘when required’ basis. The protocols we looked at for these medicines were inconsistent and did not always include information such as variable dosage and maximum daily dosage when using these medicines, although this information was on the prescribers label. There were inconsistencies with body maps being used for the application of pain relief patches. Medicines that required additional storage measures were stored correctly, and stock balances were accurate.

Staff implemented and followed best practice guidance, for example, they ensured the relevant professionals and people’s advocates were involved in discussions surrounding covert administration. Relevant staff completed training in medicines and there were systems to complete continual competency assessments.