Archived: 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

The key question of safe was rated as good at our last inspection. At this assessment the rating has deteriorated and the key question of safe is now rated inadequate. During our assessment of this key question, we found various concerns including the management of risks to people’s health and wellbeing, infection prevention control and safe management of medicines which resulted in a breach of safe care and treatment. We found concerns around the environment in which people lived including food hygiene and fire prevention systems which resulted in a breach of premises and equipment. You can find more details of our concerns in the evidence categories below.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People had experienced falls where safeguarding procedures had not been followed. Incidents had not been reported, investigated and risk assessments had not been reviewed to ensure people’s safety.

Leaders told us they were open to feedback and showed a willingness to make improvements. Feedback from staff and leaders showed there were inconsistencies in the approach to learning, as safety events were not investigated robustly, and lessons were not learnt as a result. Staff told us how they recorded incidents in the daily care notes. The manager told us, “Safety is a priority, however there isn’t currently any robust systems in place for recording the incidents and accidents to learn from.”

The management and oversight of accidents and incidents was poor. The provider had limited oversight of concerns and incidents. Not all risks were identified and acted on appropriately to ensure people’s safety or look for ways of learning. Staff told us of people who had fallen. The falls had not been reported as safeguarding concerns, investigations were not carried out, and they could not demonstrate any learning or improvements they had implemented.

We received mixed feedback from families about their experiences. One relative said, “I have not been included or involved in the transition of care from hospital to Oaklands for [name of person].” The manager failed to complete a pre-admission initial assessment of one person to Oaklands, this meant staff would not know the person’s needs, risks, history, or preferences.

The Provider acknowledged the failure to ensure assessments and care plans were fit for purpose. Assessments and care plans lacked significant information about people’s care needs. This had the potential to impact on care provided to people and information sharing with other services in an emergency, such as paramedics The manager told us they felt under external pressures to accept a new care package, and therefore admitted the person without undertaking formal assessment of the persons needs. The provider and manager told us they had learnt from this experience and would implement a more robust assessment of new care packages going forward.

A professional told us, “The manager relied on the information given to them as correct and didn’t complete their own assessment and that is possibly a contributing factor to what has gone wrong’ for one person."

People were not supported to move safely between different services. Effective assessment and discharge arrangements were not in place. People’s care plans did not contain important information of regular visits from professionals.

One relative told us how their family member had been able to leave the service without staff knowing. They were reported missing to the police, and this placed them at risk of harm.

The manager did not demonstrate a good understanding of safeguarding. For example, they did not know how to make a safeguarding referral to the local authority or know how to identify what needs to be reported. The manager was, however, new in the role and willing to learn. Staff said they would report concerns to the manager or directors. They did not mention whistleblowing processes if they were worried about how concerns were being dealt with internally. However, one staff member said there was a number to call if needed in the office. Staff did not tell us about other organisations they could report concerns to such as the local authority, CQC or the police.

We observed people at risk from infection prevention and control concerns, environmental concerns from construction works, poor care plans and lack of risk assessments. We observed the managers lack of understanding of how to safeguard people and what action to take when things went wrong. We have told the provider they need to make improvements.

Safeguarding systems were poor and ineffective. There was no effective oversight of safeguarding matters by the service. This meant not all safeguarding concerns had been referred appropriately to the local authority for investigation. We asked the provider to make an individual safeguarding alert for medicine errors we had identified during our assessment. There was no process or system in place to analyse safeguarding matters to identify themes and trends, learning and reduce the risk of reoccurrence.

People were not always empowered to make decisions about their own care. People were not supported when making choices which could be considered unwise, placing them at the potential risk of harm. One person was going against the advice of professionals that placed them at risk. This had not been discussed with the person or their relative. People told us they felt safe with staff and told us staff supported them while using their equipment such as the hoist and wheelchair. A person told us staff made sure they were safe and comfortable when using the equipment.

A staff member told us, “The risk assessments I think are there if we need them, I don’t think I have read many, but we get to know people’s risks and how to support them by talking to each other.” Another staff member told us they had read all the care plans, but risk assessments have not been made available.

Our observation of staff found that they did not support people in a way that was safe and supportive. We observed a staff member being asked by a person to use their standing device for exercise purposes. The staff member did not show any awareness of how to assist them or verbal or physical encouragement to do the task and this resulted in the person not reaching their goal. This did not enable the person to do something that mattered to them. Another staff member was observed taking a person back to their seat when they had just got up. There was no discussion with them about what they needed, where they wanted to go and how they felt which could have resulted in risks to their health and wellbeing. The person was left back in their seat and prevented from doing something that was important to them.

Processes were not effective in assessing risks, and we identified multiple people's care records which were incomplete, contradictory, or inaccurate. There were multiple areas of concern which were not identified and addressed to mitigate risk in people’s care records, including choking, falls and diabetes. We identified one person had no risk assessments in place for known risks including vascular dementia, aggression, suicidal thoughts, and road safety. There was insufficient guidance in place to inform staff how to support someone if a person was to choke. Guidance to inform staff how best to support a person who was distressed was not in place.

People did not experience a safe place to live. People did not have access to a bath or shower for weeks due to both bathrooms being renovated at the same time. People were tolerant of the renovation work being completed on the service. One person said, “There is so much going on, there are people in and out all the time.” Another person said, “I just try and stay in my room, and keep out the way. It’s much calmer.” A relative said, “We were made aware of the works going on before [relative] moved in. The home was very open about this; it's not going to be forever so we can't judge them on this." People experienced a hazardous environment that included work tools, paints, trip hazards and poor hygiene in the kitchen. People experienced a non-secure garden that they could exit through the hedge line, this put people at risk within the community.

The provider told us when they bought the service there were safeguarding concerns within the environment that they felt needed urgent attention. The provider then started renovation works to improve the environment which included all areas of the service and the garden. The staff told us the renovation works being undertaken would make the service better. A staff member said, “It will be great for people when it’s all finished. But it is a bit difficult at the moment.” Another told us, “The home is getting better now they are doing some works. Before it was terrible trying to keep everything clean, impossible mostly. Try to keep on top of it now.” Another said, “It is hard to assess and monitor everyone with the works going on."

The lounge and dining area was chaotic on the first day of the inspection. Work men were using this area to go back and forth without due regard for people using the service. People did not have a calm and relaxing environment to enjoy their meals, for example one person who was being assisted with their breakfast in a noisy and stressful atmosphere. Staff were trying to assist one person who was distressed, loud and very agitated which created confusion, noise, and an unsafe environment for people to be in.

The building was in the process of being renovated, however the building work was not being managed well. There was no planned approach to the work being undertaken to keep the disruption to people at a minimum. Fire exits were blocked with equipment. Mop heads placed on window ledges to dry. Building equipment such as glue, paint and decorating equipment stored in bathrooms and the cupboard which contained all cleaning substances was not locked and easily accessible to people. There was no risk assessment in place that covered the extent of the works and how these needed to be managed within the care home environment. One workman told us they had created their own risk assessment for the works. Where risk assessments for the environment were in place these did not have enough information to mitigate risks. Some people did not have risk assessments in place for the specific equipment needed to support people safely. Health and safety audits were not regularly completed such as fire alarm sounding and hot water checks. The provider failed to adequately identify issues seen on site by the inspection team. This meant we could not be assured the provider was effectively identifying and addressing safety issues within the environment.

We received mixed feedback from people and their families as to safe and effective staffing. A relative told us, “There is little interaction or stimulation from staff with people.” Another said, “I think staff are doing their best.” A person told us, “I don’t know if there is enough but staff pop in and ask if I want a drink or snack.” Another person told us, "We have some new staff who have only been here a while, have not really talked to them much but they are friendly.” On the first day of inspection, one person who was new to the service was very distressed which meant a staff member had to support them on a one-to-one basis. Other people therefore did not always get the attention they needed and deserved. For example, we did not see any staff spend time engaging with people with dementia in a meaningful way.

Staff told us generally there was enough staff to support people (5 care staff on a shift including a senior care staff member) and they were now a consistent team. However, due to the need for a staff member to support one person, they were short one staff member for the shift. A staff member told us, “I am now to spend time with [Person’s name] so will be focussed on them.” We were told that later that day the person needing the one-to-one support had left the building unnoticed by staff and been found in the community and bought back by Police. On the second day of inspection, the shift had the same number of staff on duty (5) and had not been increased due to the continued need for one-to-one support for one person. We saw that at times the staff member allocated was not always with the person as they were completing other tasks for people, this left the person needing the one-to-one at risk. Staff told us they were busy but were managing as they worked well together. A staff member said, “I do a 12-hour shift 4 times a week, and most of us work around 40 hours.” A staff member said, “I feel I get on well with everyone. I can speak openly; it is a supportive team and I like working here.”

We observed staff were not always deployed where needed to provide high quality care to everyone. Whilst staff completed physical tasks for people, staff were not allocated to spend time providing stimulation or conversation, alternative activities to sleeping, walking with people where they wanted to go. If they did get up, we saw people were taken back to their chairs to sit down again as staff did not have the time to spend with them. Staff used equipment such as hoists and wheelchairs safely. We observed staff were competent in supporting people with moving and handling around the building. One person who had been hoisted into bed, was relaxed, and smiling and said staff had, “Done everything well.”

The provider had not always recruited new staff in line with legislation to ensure they were suitable for their job roles. Some information was missing from the staff recruitment files we saw, such as gaps in a person’s employment history and lack of information related to people’s sponsorship agreement. The provider and manager were not aware of the requirement to have a full employment history of all staff. Improvements were made to the recruitment process during the assessment. Staff supervision and competency checks were not as robust as they should be. A supervision system had been implemented and the manager told us they had not got round to supervising all staff yet. We saw signed documents for 5 staff members for January and February 2024 and 3 out of 5 contained minimal information about their job role, any concerns or professional development discussions. Staff had completed training and qualifications relevant to their roles in previous employment. Staff had undertaken updated training in moving and handling people and medicines administration. Staff told us about the training they had in a previous role which they could easily transfer to working at Oaklands. A staff member said, “I had plenty of training in care in my old job so have had refresher training in medicines and moving and handling people especially, so we get it right and do it properly.” An induction process was in place so that staff were familiarised with the building and people.

People were not always protected from the risk of infection as staff were not consistently following safe infection prevention and control practices. We found widespread failings in the kitchen that included the risk of contamination from spoiled foods, mop heads were left to dry along a window seal in a corridor, and there were debris from refurbishment on the floor and walkways. People’s bedrooms were clean and tidy, staff employed as cleaners knew people well.

The provider acknowledged the kitchen was in poor repair and told us the kitchen was part of the refurbishment plans. An agency cook told us there was no systems in place for recording and promoting good standards in the kitchen. Staff told us there were no due diligence forms such as an in-depth cleaning schedule, record of temperatures, record of fridge checks, food safety and hygiene policy. Staff told us the night staff clean the kitchen but there was little evidence to suggest the cleaning was enough to keep people safe and protected from the risk of infection.

On both days of the site visit, we found the kitchen to be unclean, with crowded worktops, damaged cupboards, and heavily used chopping boards. We found vegetables not being stored correctly, foods past their use by date, evidence of cross contamination in the fridge. We found the hand washing facilities in the kitchen could not be accessed due to overcrowded worktop and floor space. This meant service users were placed at risk of harm from infection. We found a large pile of stained mixed clothing on the floor in the laundry room and were told this would remain there until night staff do the washing, this was an infection control risk. We observed staff used personal protective equipment and cleaning products available to them.

The provider failed to ensure people were protected by measures which reduced the risk and spread of infection. During the assessment we identified multiple concerns with the cleanliness of the kitchen. There were no robust due diligence checks and food safety and hygiene policy available in the kitchen which had not been identified prior to our visit. This placed people at an increased risk of infection.

People had experienced medicine errors, for example the wrong medicine at the wrong time. There were no PRN [as and when required] protocols in place to provide guidance for staff about how and when they would need to give medicines such as pain relief or medicines to support people experiencing distress or anxiety.

Leaders told us the medicine errors we identified during our inspection had been discussed with staff, however they did not have any documentation to support this. Staff were able to explain the process around safe administration of medicines. Staff explained that people have the right to refuse medicines and what action to be taken when this happens.

The provider had failed to manage medicines and systems associated with medicine administration safely, there was no efficient monitoring of medicine or auditing systems in place. Medicine administration errors had not been identified, acted on or investigated to mitigate the risk of potential reoccurrence. There were no effective systems in place to provide medicine when and how people needed them. During the inspection, we found medicines in the controlled drug cabinet for a person who was no longer living at Oaklands. Our medicines audit found the controlled drug stock did not match the stock recorded in the controlled book. We observed a clean medicine’s trolly with items labelled correctly. Staff were able to explain the medicine recording process.