Oaken Holt Nursing and Residential Home

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• 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

We assessed a total of 8 quality statements from this key question. We identified 4 breaches of the legal regulations relating to safe care and treatment, safeguarding, notifications and governance. Risks to people were not always effectively recorded, and safeguarding referrals had not always been made. Staff were safely recruited; however, appropriate staffing levels were not always in place to ensure people received safe, good quality care that met their needs. People and their relatives expressed concerns about the safety of the care provided. Systems and processes in place to ensure people’s care plans and risk assessments were up to date were not always effective. The environment was not always managed safely. The provider had introduced new systems to ensure there was good oversight of the home. Although some concerns found during the assessment had been identified by the service, the provider needed time for changes to be embedded to improve the quality of care and support.

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.

Relatives gave mixed reviews about their experiences of being kept up to date about changes to their loved ones. We were told “I get informed sometimes, but I’m not sure if I’m informed about every incident” and “I don’t get informed within a timely manner, once [relative] went to hospital and I didn’t know for a few hours.” People told us changes to the service were not always communicated well. One person said, “Three nurses have gone [to another service] it was a real shock, especially as the brochure makes such a feature of the nurses being here, but their move was not advertised, they should tell us in a Residents Meeting.”

Staff demonstrated an understanding of the procedures for reporting and recording accidents and incidents. Staff were aware of the falls protocol and the steps to follow when someone experienced a fall. Falls were discussed within handovers however staff told us debriefs or formal learning was not always shared amongst the team. Staff felt increases in falls was a reflection of staffing numbers.

Falls protocols and monitoring were in place. The provider had a system to review accidents and incidents but had failed to identify the shortfalls found during assessment. For example, accidents and incidents were not always recorded in a timely manner, not all falls were recorded within the falls analysis, or in the accidents and incidents tracker. One person had a fall which resulted in a hospital admission due to an injury to the head, the falls analysis recorded this person sustained no injury, which did not reflect the hospital admission. This meant there was not always a clear oversight of falls, or what action was required to keep people safe.

People told us they were disappointed they could no longer rely on the services transport van. Some people said they had to cancel hospital visits as the service had been unable to use their own adapted van. Relatives we spoke to had not always had positive experiences of their family being supported to hospital following incidents. At the time of the assessment, the provider was in the process of ensuring staff were trained to use the transport.

Staff and leaders understood their responsibilities for ensuring safe systems of care to ensure people received continuity of care, including working with other professionals and services. However, staff felt pressured to provide additional support to agency staff to ensure the correct procedures were followed which took time. Staff also felt communication with professionals was, at times compromised by the use of agency staff who did not know people well.

Professionals working with the service told us there was a period of learning around appropriate referrals to services, but this had now improved. Referrals were appropriate and there was learning from previous referrals in place. However, further improvement around contacting partners for administration of medicines for symptom control was required.

Although processes were in place to help ensure people received continuity of care and appropriate referrals to professionals took place when needed, the advice or outcomes from these referrals were not always recorded in care records. This meant the information was not always available for care staff to deliver the right care in line with their outcomes from health professional input.

We received mixed feedback from people and their relatives when it came to keeping people safe. Although people told us they felt safe, we also heard people did not always have a choice about who supported them. One person told us “I would rather have a lady to help me, I always hope that they are carers I know. I won’t let men wash me, unfortunately we mostly have men at night.” Relatives and people, we spoke to felt the home was understaffed which resulted in longer wait times and impacted peoples experiences of care.

Staff told us they would report concerns to senior management, but were not always clear on who they would report concerns to externally. We heard good examples of how staff supported people with limited capacity. Staff were not always assured people in the home were safe due to the use of agency staff, and raised concerns around incidents they felt could have been avoided with the use of experienced staff. Documentation highlighted people had experienced injury after falls, including bruising and skin tears. It was not always clear how people sustained these injuries and if they had been reported to the appropriate authority. We discussed unexplained injuries with the management team, and asked that records be reviewed to include actions, investigations and were reported to the appropriate authority. Safeguarding referrals and adequate record keeping had been added to the services improvement plan following onsite feedback.

We observed the correct equipment in people’s room, however sensor mats and crash mats next to beds meant people did not have access to fluids as tables were required to be moved away from the bed. We told the provider about this, and they told us they would take action.

The provider was not always complying with the Mental Capacity Act. Where people required lawful authorisations to deprive them of their liberty, there were not effective processes to monitor and follow up on the process of applications. For example, care plans documented families or significant others had consented for people using the service to have their photographs taken, however there was no evidence families or significant others had Power of Attorney or Court of Protection authorisation in order to make decisions. This meant people may have been deprived of their liberty for the purpose of receiving care or treatment without lawful authority. The provider told us they put plans in place to address the concerns found during assessment to ensure all the principles of the Mental Capacity Act were followed in all areas of the service. There was a safeguarding log in place, however not all safeguarding had been recorded and therefore we could not be sure internal investigations, root cause analysis or thematic analysis of safeguarding incidents were carried out. We had not always been made aware of any ‘notifiable’ incidents. A notifiable incident is an unexpected or unintended event that could cause harm to the person, providers are required to report these incidents to the Care Quality Commission. There was limited evidence available to demonstrate how safeguarding was discussed with staff as detailed within the services safeguarding policy, the policy did not contain contact information for the safeguarding team in order for staff to raise their concerns externally.

We received mixed reviews about how people were involved to manage risks. One person told us “I was given the choice when I came here whether I continued to self-medicate or let them do it for me, I agreed it was simpler for them to do it.” However, other people told us they were not always happy with their care. We heard people waited long times to receive support with personal care due to staffing numbers, which impacted on their medicine times. People we spoke to felt they were often restricted to leave the building in order to access the grounds to sit outside, as staff felt they would not be safe on their own or there were no staff available to escort them.

The manager outlined how peoples' changing needs were addressed through monthly reviews of care plans and risk assessments. Staff reported they could easily access risk assessments and care plans, which were updated frequently, however staff did not always get time to review care plans due to staffing numbers.

We observed the correct equipment in people’s room, however sensor mats and crash mats next to beds meant people did not have access to fluids as tables were required to be moved away from the bed. We told the provider about this, and they told us they would take action.

People’s records were not always consistent, accurate or up to date in order to ensure appropriate measures were in place to reduce the risk from falls, skin pressure damage, medicines, weight loss, capacity, pressure care and nutritional needs. We were not assured the provider was using information gathered to ensure people’s assessed needs and risks were minimised. This meant we were not assured care was provided in the safest way. For example, conflicting information was documented around the level of support required with people’s nutrition and hydration. Within care planning documentation it stated one person required a level 4 food type, however their choking risk assessment stated level 7. Another person with diabetes was not included on kitchen staff’s records as needing a diabetic diet as specified in their care plan. This conflicting information could present risks regarding eating and drinking. One person had a risk assessment in place for a medicine. It stated in the event of a fall, if there were signs of head injury to contact 999. This person had a number of unwitnessed falls and was unable to verbally communicate to explain what happened and if they were hurt, therefore staff may not be able to identify if the person had banged their head when falling. There were a number of incidents where 999 had not been contacted. This could put people at risk of internal bleeding which could cause harm. Peoples care plans had not always been updated following falls, however the service had identified the need to ensure staff had received effective training in care plan coaching so care plans were effectively updated following falls. The provider had a plan in place to condense care planning so information about people and their needs would be easier to find.

People and their relatives felt the home was clean and commented they were happy there were access codes to keep their loved ones safe. People had reported equipment not working to management but had not received a response. We also heard people could not always leave if they wanted, “I don’t feel very secure although I am not allowed to make a step outside the doors without an escort- I find that irritating.” One person said, “I am awakened every morning by night staff opening my door and shouting ‘Good Morning- are you alright?’, they then slam the door behind them and leave.”

Some staff felt the home was safe to meet the needs of people. However, others expressed concerns about peoples safety due to staffing levels working across two buildings and the buildings security.

Our observations raised concerns about the safety of the environment. For example, there was no lock to the staff room. There was a wooden gate at the top of steep steps near rooms which posed a risk, as people may try to climb over this gate. A room containing PPE and hand gel was unlocked. This room had stairs leading up to a locked gate. There was a risk people could gain access to this room and attempt to walk up the stairs and access items such as hand gel. The service had not identified this as a concern but told us they would take action.

The provider had not identified all concerns found during the assessment around the safety of the environment. The management team had identified actions to make the building more secure, further actions were in place to ensure the building was made secure until further work was completed.

People and their relatives spoke highly of the staff. People felt permanent staff were kind and were described as being ‘amazing’. People felt safe with staff, and we received no complaints about staff being untrained, however relatives told us “I feel that [relative] is physically safe- but psychologically I am not so sure- I am not sure all the staff have the right knowledge and understanding.” All people we spoke to noticed a difference in the number of staff available, and the impact this had on people and the home. People told us there were not enough staff to safely meet people’s needs. We heard, “Everything has gone downhill now, there are not enough staff and not enough carers” and “There are lots of changes of staff here, there is never any certainty about who will be dealing with you.” People also told us there were too many agency staff who didn’t know the service or the people and often seemed disinterested, as well as times in which people heard staffs’ frustration in the way of disagreements between staff.

Staff felt they had the necessary training and could access further training if required. Staff we spoke to were concerned about the number of permanent staff and the high use of agency staff impacting on the quality of care. We heard “We need extra carers, residents have to suffer if we don’t have staff, everything’s delayed”, “People are not safe with the level of staff, the management try the best to cover the shifts” and “There's not enough staff, they are using a lot of agency, which is not nice for residents, sometimes it can be only one permanent staff. Both day and night, they are always short of staff.” The management team told us of their efforts to recruit more permanent staff and had plans in place around recruitment.

We observed staff throughout the day. Some agency staff seemed disinterested and rarely conversed with people. Some people were not dressed until later in the morning. People told us they were unwashed and dressed for the day as “Carers are getting later and later now; it is always after ten when I am attended to now.” Throughout the day staff walked into people’s rooms unannounced, without knocking, waiting for the resident’s permission or acknowledgement before entering.

There were processes in place to ensure staff undertook appropriate training. We reviewed the rotas and the staff dependency tool along with the recruitment process. Staff had been recruited effectively, although there were some gaps in documentation, this had been identified and the provider was in the process of accessing the missing information. Rotas were created based on a dependency tool of people’s needs; however, people’s assessments were not always reflective of their needs, and double handed care had not been taken into consideration. Daily notes documented people had to wait to be supported with repositioning as staff had to wait for a second member of staff to support them. There was an action plan in place around recruitment. Plans were in place to ensure all agency staff had profiles and adequate inductions, as well as ensuring hospitality was covered for the days there were no hospitality available.

People and relatives were happy with the cleanliness of the service and confirmed staff wore appropriate Personal Protective Equipment (PPE) when providing care.

All staff we spoke with showed good understanding of their role on preventing the spread of infection. Staff we spoke with told us there was enough PPE available in the home.

Staff were practicing good IPC (infection prevention and control) in their tasks. Not all PPE storage rooms were locked and there was potential for people to access hand gels.

Processes were in place to help ensure the safety of the environment and equipment. Safety checks on the environment and equipment were carried out at the required intervals and prompt action was taken to address any safety concerns. An up-to-date PEEP (Personal emergency and evacuation plan) was completed for each person and we saw where follow up actions around clinical PPE use and waste had improved.

We received mixed feedback about medication. People discussed the changeover in nurses, “The proper nurses were moved to [another service] we weren’t told and now we have senior carers but they are not fully qualified” and “I definitely feel more vulnerable with the three nurses going, the [senior carers] are ok but they are not the same, there is no reassurance now like there used to be, you want things to be stable, not to get worse”. Other people said their medication and its administration was unaffected.

Staff confirmed they had completed training in medicines management and had their competencies checked. Staff gave good examples of where they contacted professionals such as the GP regarding people’s choking risk and the need for oral solution medicines, but did not always have confidence in agency staffs’ ability to administer medicines adequately. Management told us there had recently been medication audits implemented, and documentation put in place such as PRN [when required medicines] protocols to ensure safe documentation was in place.

Administration of people’s medicines and actions taken were not always documented. We reviewed whether people were administered their prescribed medicines by checking the Medicine Administration Records (MAR). One person’s care plan stated they were prescribed PRN paracetamol. However, the MAR stated this was a regular medicine to manage pain, the pain assessment stated the person was not able to verbalise if they were in pain. Another person had not received prescribed medicines on a number of occasions because they were asleep. Although the person may not have experienced any significant symptoms for 1 or 2 doses, the person’s MAR identified this occurred a number of times a week for various medicines, including blood thinning medicines. We saw no documented follow up to ensure risks were mitigated for missing these medicines. Medicines were stored securely and safely, including controlled drugs, PRN protocols were available in people’s support plans, and risk assessments for certain medicines were in place.