Oaklands 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.

This is the first assessment for this registered service. This key question has been rated good.

This meant people were safe and protected from avoidable harm.

This service scored 66 (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.

Systems were in place to ensure accidents, incidents, and near misses were consistently monitored and reviewed. Incidents were reviewed collectively to identify themes, trends, and wider learning, enabling the service to implement preventative measures and strengthen overall safety.

Information and learning from incidents were effectively shared with staff through daily huddle meetings, as well as during staff meetings and supervision sessions. This ensured staff remained informed.

The provider had taken a proactive approach to addressing concerns identified during the assessment process and had worked in partnership with the local authority quality assurance team to drive improvements.

The provider always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services.

The Registered Manager worked collaboratively and proactively with the integrated care board (ICB) to enhance the hospital discharge process, particularly in relation to the transfer of discharge document (TOC). This partnership working has driven measurable improvements in the timeliness, quality, and consistency of information received. As a result, people experienced safer, more coordinated hospital discharges into the service, with risks anticipated and managed effectively from the point of admission.

The service has further strengthened its approach through the introduction of a dedicated Admissions Officer role. This has ensured a highly personalised and responsive admissions process, providing prospective residents and their relatives with a consistent, knowledgeable point of contact. Feedback and evidence indicated this reduced anxiety, improved communication, and enabled smoother, well-planned transitions into the service.

There were systems and pathways in place to support the sharing of information across the service. Staff had immediate access to comprehensive, person-centred information about people’s needs, preferences, histories, and risks.

The provider did not always ensure people were protected from avoidable harm and risks to their safety were consistently managed. We identified concerns in relation to moving and handling practices which had the potential to place people at risk of injury. However, where concerns were identified during the assessment, the provider responded promptly and took action to address them.

We identified concerns in relation to moving and handling practices which may place people at risk of harm. One person told us, “They get me up from the bed by holding both my hands. I have 1 carer each side of me.” While onsite during our first day we observed one person being supported using an underarm lift, which is not considered safe practice and may cause discomfort or injury.

These concerns were discussed with the Registered Manager and location manager on the first day onsite. On the second day of our visit, evidence was seen to confirm discussions had taken place with staff regarding safe moving and handling techniques and plans for competency assessments were in place.

Safeguarding concerns were reported appropriately. Records showed concerns were raised with the local authority when required, and statutory notifications relating to safeguarding alerts were submitted to the CQC in line with regulatory requirements.

The provider 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.

There was evidence people were supported to access activities within the local community, including visits to the park, pub, and local shops. This demonstrated a positive approach to enabling individuals to maintain independence while remaining safe.

People were supported to access appropriate equipment, including electronic mobility aids, tailored to their individual needs. Consideration was given to the suitability and safety of this equipment, ensuring it supported people to mobilise safely both within the home and in the community.

Risks associated with activities and equipment were discussed with people, and potential risks had been identified, assessed, and managed appropriately. This reflected a person-centred approach, balancing safety with individuals’ rights to take positive risks and maintain meaningful lifestyles.

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.

During the first day of the inspection, we identified window restrictors in one part of the building were not secure or tamper-proof. We were informed there were planned renovations which would include the installation of new windows. During this visit, we found areas of damaged and raised flooring within a connecting corridor and a communal bathroom, presenting a potential trip hazard. Additionally, sluice rooms were observed to be unlocked, leaving hazardous substances accessible to residents, staff, and visitors.

At the follow-up visit, we observed appropriate action had been taken. Window restrictors had been replaced with tamper-proof devices, reducing associated risks and improving safety. Flooring damage had been repaired or made safe with appropriate taping to minimise trip hazards. Sluice rooms were found to be secured, ensuring restricted access to hazardous substances.

During our first day, the main communal area was observed to be loud and potentially overwhelming, with multiple activities taking place simultaneously across different parts of the space. Observations indicated not all residents appeared comfortable within this environment, with some showing signs of unease or disengagement. At the follow-up visit improvements had been made. The layout of the environment had been adapted, and plans were in place to relocate louder activities to alternative areas. These changes were observed to have a positive impact, with the communal environment appearing calmer and residents presenting as more settled and at ease.

There were systems in place for environmental audits and oversight. These had identified some of the issues such as the damaged flooring, and maintenance plans were in place to address this. However, audits had not identified concerns relating to insecure window restrictors, unsecured sluice rooms, or the potentially overwhelming communal environment prior to the assessment.

The provider generally ensured there were enough qualified, skilled and experienced staff to meet people's needs and staff received appropriate support, supervision and development. However, some inconsistencies were identified in the delivery and monitoring of care, particularly in relation to repositioning and people's experiences of night-time response times.

One person’s daily notes indicated repositioning was not happening 2 hourly as required, staff were unable to explain why this was not occurring as noted within the persons care plan. Although, no impact on the person was observed during our assessment.

Staff spoken with during the assessment told us they felt there were enough staff on duty to meet people’s needs, 1 staff member told us, “We have enough staff on every shift, shift patterns are well organised and there are enough staff”. However, feedback from people using the service indicated response times during the night could be inconsistent. One person told us, “If I press my buzzer in the night, it does take longer.” Another person told us, “I do ring my bell at night and they can take so long I have to use my pad. I would prefer to go to the toilet, but I can’t without their help.”

The service did not have a system in place to audit call bell response times, as the current system did not capture this data. This limited the provider’s ability to effectively monitor and evidence response times. However, we saw monthly night-time spot checks were undertaken, which had not identified concerns with response times.

Following feedback during the assessment, the provider took appropriate and timely action to address this gap and began the process of updating the call bell system to enable monitoring of response times.

Recruitment processes and procedures were in place and were being followed, helping to ensure staff were suitable to work with people using the service.

Staff had received appropriate training to support them in their roles, including safeguarding adults, manual handling and medicines administration. Following our observations, discussions were held with the provider regarding manual handling practices. The provider confirmed competency assessments were already in place and completed regularly. However, observations made during the assessment indicated some inconsistencies in the application of manual handling techniques in practice. The provider advised additional competency observations and oversight would be undertaken to reinforce safe and consistent practice.

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.

During the assessment, the home was observed to be generally clean, with particular attention to communal areas. Communal bathrooms and toilets were clean, tidy, and free from clutter, supporting effective infection prevention and control practices.
However, in the communal bathroom, the shower head was noted to be mottled, and a tap was cracked. These issues could hinder effective cleaning and infection control. Additionally, we observed damage to bucket chairs, which may impact the ability to maintain appropriate hygiene standards. The provider had already identified the damage to the bucket chairs and was able to demonstrate plans were in place for their replacement.
We observed the hand sanitiser unit located by the entrance was empty at the time of our assessment, reducing immediate access to hand hygiene for staff, visitors, and residents.
The provider responded promptly to concerns raised during the assessment, taking action to replace fittings in the communal bathroom and progressing arrangements to replace the damaged bucket chairs.

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

Medicines were observed to be stored safely and in line with current guidance.

During the assessment visit, discrepancies were identified between recorded stock levels and actual medicine counts on several occasions. This raised concerns regarding the accuracy of medicines administration and recording systems, particularly as the electronic medicines administration record (eMAR) did not highlight any errors.

At the second visit, the provider explained the electronic devices used for the eMAR system had not been synchronised, resulting in returned medicines not being accurately reflected in stock balances. Evidence was provided to demonstrate this issue had been discussed with staff and escalated to the system provider for resolution. On rechecking during the second visit, stock counts were found to be accurate, providing reassurance immediate risks had been addressed.

Protocols for ‘as required’ (PRN) medicines were in place and clearly outlined the circumstances in which these medicines should be administered, along with guidance on actions staff should take if medicines were required over a prolonged period.