The Oaks Care 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 identified 4 breaches of the legal regulations in relation to safeguarding, safe care and treatment, the environment and staffing. The breach relating to safe care and treatment was a continued breach of regulation. People were not protected from abuse or avoidable harm as senior staff did not always report concerns to relevant safeguarding authorities. Learning from accidents and incidents was not in place. People and relatives told us there were not enough staff and they had to wait for support. Potential risks in the care environment and equipment had not been addressed, staff and people told us there was not enough suitable equipment in place to ensure people could access communal space. Risks to people’s safety had not been effectively managed, monitored, or mitigated. Medicine processes required improvement.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We were not assured incidents and complaints were appropriately investigated and reported. There was no effective learning from accidents and incidents. A relative told us they had consistently raised concerns and when we viewed the complaints recorded, none of these concerns had been logged.

There was not a culture of learning at The Oaks Care Home. We identified 2 safeguarding incidents which had not been reported to the safeguarding authority and numerous safeguarding incidents which had not been reported to CQC. We also found complaints reported to senior staff by staff, people and relatives had not been included within the complaints overview. Senior staff did not complete any reflective practice or debriefs when an incident or accident occurred to allow learning to take place. This meant people were at risk of incidents and accidents re-occurring.

The provider failed to ensure there were systems and processes in place to enable a learning culture. We found there was no process or system in place to learn and reflect when things went wrong or from incidents and accidents. Staff and people living at the service were not always provided with the opportunity to reflect after incidents, to ensure learning and improvement could occur. Accidents and incidents were logged but there was no process in place to identify themes and trends to avoid reoccurrences. The views of people who use services, partners and staff were not always listened to.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us of incidents they had reported which we found had not been reported to relevant safeguarding agencies or CQC. This meant we were not assured people were protected from abuse or avoidable harm. We received mixed feedback from people about their safety. A person told us, “Some staff are lovely, the nurses I would give 11 out of 10, some carers I was frightened of they were rough with me.” We did also receive comments from people and their relatives who were positive about their safety. A relative said, “They are good with [family member], I believe they are safe here.”

Staff employed in the service had not always protected people from abuse and avoidable harm. Staff we spoke with told us they reported bruising and injuries. When we asked a senior staff member if 2 incidents communicated to us from people had been reported to the relevant safeguarding authority, they told us they had not been reported. When we viewed records of a person the staff member told us about an injury they had reported. However, whilst this injury was recorded in care notes and dressed by qualified staff who also took a photograph of the wound, there was no accident or incident report completed or any investigation into how this person who was cared for in bed sustained this wound. Staff understood how to report safeguarding concerns. However not all staff were aware of the providers whistle blowing policy or who they could report to externally. A staff member told us, “I would go to [senior staff member], I have never been told who to report to externally or told about the whistle blowing policy.”

We were not assured people were appropriately supported to avoid harm and abuse. One person had an alarm on their bedroom door as they had been identified as a risk to themselves and others. We observed them leaving their room and the alarm sounding, staff did not respond to this immediately and the person walked to the lounge area and sat down prior to a staff member noticing they had left their bedroom. This meant we were not assured staff were keeping people safe. However, we did observe during the assessment other people were responded to safely.

There was no effective oversight of incidents and accidents to safeguard people from potential abuse; they were not investigated and reported appropriately to reduce the risk of reoccurrence. We identified wounds which had not been reported as accidents or incidents. On a review of accident information, we found an incident of a sustained injury that had not been reported appropriately to safeguarding authorities or CQC. The Mental Capacity Act 2005 (MCA) provides a legal framework for making decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to make decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). On day 1 of the assessment, we identified 17 bedrooms in Emerald (which is an area for people with dementia nursing needs) that had door gates fitted. Care records showed 8 people did not have appropriate mental capacity assessments or best interests’ information in place. This was addressed by day 2 of our assessment following feedback given to staff There was not an effective process in place to manage DoLS applications or authorisations. We requested an overview of people’s DoLS status and found on Emerald there were 9 people where senior staff could not identify if either an application or authorisation was in place. When we requested a response to these gaps a senior staff member told us following the previous manager leaving, they had been unable to find the relevant documentation. This meant people could be unlawfully deprived of their liberty.

People were experiencing deterioration of their health conditions, but we found no evidence that people or their representatives had been involved in how people's risks were managed. Examples of such risks were skin deterioration, choking and dehydration.

When we spoke with senior staff at the start of the assessment, we asked for the names of people with pressure injuries or currently receiving treatment for wounds. The staff member identified 2 people. However, in a review of people’s care records we identified 3 other people receiving treatment for wounds. One person was recorded as having a significant wound. The clinical manager subsequently reported this injury to relevant agencies recording they had not been informed of the deterioration. We received mixed feedback from staff about the handover process. A staff member told us, “We have a handover and the nurses let us know what happened the day before. If we are off for a few days, we are not always told everything as they only tell us about the night before.” Another staff member said, “Staff do a thorough handover and every month we have resident of the month, which includes risk assessments, updating care plans and reviews.”

We observed on Emerald most people were in bed or in their room. Senior staff had not considered in full their risk of isolation. There was not enough equipment to support people to access communal areas when they wanted to. As recorded in more detail in the safe environment section of this report.

Risk assessments were in place for people where a risk had been identified, however they were not always followed by staff to ensure risks were mitigated. Monitoring charts for repositioning, fluid recording and weight monitoring were not being completed in line with people’s care plans which meant people’s risks were not being fully mitigated. Some risks in care plans had not been fully updated. One person had recently been seen by the speech and language team (SALT) who had advised the person could have pureed food. Their choking risk assessment stated they were ‘Nil by Mouth’. This meant the person was at risk of receiving inappropriate nutritional care. Another care plan recorded a person with significant weight loss should be weighed weekly. On a review of weights this was not being completed. We also identified health and safety risks at the service. There were no Personal Emergency Evacuation Plans (PEEP) held within the service's emergency grab bag. The emergency grab bag did contain a rag rated overview of people which was dated 08 May 2023, most people on this list were no longer at The Oaks Care Home. Unlabelled and undated items were found in fridges and 2 wardrobes were not secured to wall which could potentially cause harm. Following the assessment, we were informed we had been given the wrong folder and PEEPS had been updated, however we did not find any evidence of updated PEEPS in the emergency grab bag. We found Chemicals stored in an unlocked kitchen cupboard which could have serious consequences for people if ingested or swallowed. This was acted upon immediately and a lock was fitted.

People and relatives told us there was not enough equipment to support them to access communal spaces when they chose.

Staff confirmed to us they did not have enough mobility equipment to enable people who wanted to access communal space or attend activities. A staff member told us, “We have 20 people here and we only have 3 chairs so we rotate the chairs. At least 8 people have to share the chairs. We try to not deprive people of their liberty and we will wheel people in their beds to the activities.” A senior staff member told us they would order more equipment; however, they had not fully considered people’s individual needs or whether there was enough communal space available in Emerald to accommodate all the chairs.

We observed most people in Emerald were either in bed or in their bedrooms. The lounge dining space contained a picnic-style plastic table which did not look suitable for people using the service. There were 2 very small round tables again with limited space for people to use when dining. There was limited space within the lounge area, particularly if more people required access. Whilst we observed other communal spaces were available outside of Emerald, the service had not considered these areas in respect of people living in Emerald.

Processes to identify environmental concerns were not effective. The provider had not ensured people had sufficient equipment available to avoid isolation and access communal spaces. Staff repeated to us they did not have enough chairs and had informed senior staff but no action had been taken. The provider had also not considered whether there was enough communal space available if more people chose to sit or eat in communal spaces. Systems and equipment were maintained and serviced to make sure they remained in good working order and were safe to use.

People and relatives told us there was not enough staff to support them in a timely way. One person told us, “I had to wait after ringing and waited 25 minutes. It is worse on both Saturdays and Sundays; you know that it is not going to be as good then.” Another person said, “Yesterday, mid-morning I waited 30 minutes and in afternoon I waited 25 minutes, staff said they were busy with other residents in the morning and in the afternoon, there was a staff meeting.” A relative said, “One member of staff is meant to be in the lounge at all times, this does not happen. When I go in there is not a staff member in sight, residents are trying to get out of chairs and asking for drinks.” People and relatives also told us staffing levels impacted their or their family member’s choices around personal care. One person told us, “I get a shower every couple of months, I would like one every couple of weeks, it is down to staffing.” A relative said, “The care is good but we have had to push for daily showers and then it happens. But not sure we should have to push for daily showers.”

We received mixed feedback from staff about staffing. A staff member told us, “The staffing on the lower floor can be difficult as we have staff shortages and last-minute sickness.” Another staff member said, “There is always 7 on. Even at weekends we have the same staffing levels. Staff are good they will cover.” Staff told us they were not receiving regular supervision and also they did not feel listened to. A staff member told us, “I do have regular supervision. There is a lack of continuity with so many managers.” Another staff member told us, “We all had 1 supervision but it is not a regular thing.” A third staff member added, “Staff are not listened to there is no respect, this place needs a good shake up.” We received mixed feedback about the training staff were provided with. A staff member told us, “We do online training as refreshers.” Another staff member told us, “Training was basic and just eLearning. I feel that if someone was starting, they would need more training to feel confident.”

During the assessment we observed people were responded to appropriately and call bells answered. However, we did observe most people in Emerald remained in bed or their room due to lack of equipment. This meant our observations did not include what staffing would look like if more people requested access to the communal areas. A staff member we posed this question to told us if they had sufficient equipment and everyone able chose to access communal areas, there would not be enough staff to support them. We observed some staff were task focussed. There was little time spent providing positive engagement with people. The television was on in the communal area in Emerald, however, the 3 people using this area were not watching it nor were they engaged in any purposeful activity. However, we did observe positive interaction from nursing staff during the assessment who showed they knew the people they were looking after well. They showed that they had appropriate nursing skills with medicines, care practices, wound care and PEG feeding. They were approachable with staff, people, relatives and professionals.

Processes to ensure safe and effective staffing were not effective and negatively impacting on people’s care and support. Due to the feedback that people had to wait a long time for support, we requested the call bell analysis. A senior staff member told us this was not captured which meant the provider could not identify or action call bell response times. Records we looked at identified people were not always receiving fluid or repositioning as recorded in their care plans and people were not receiving baths or showers as frequently as they had requested. Staff had limited input into any discussions about how to improve their performance, or how to improve the service people received. Staff were safely recruited; we saw staff had a Disclosure Barring Service (DBS) check to ensure they had not got a criminal history that would impact the safety of people at the care home.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We could not be assured people were receiving their medicines safely. We found stock level discrepancies. This meant people may not be receiving their prescribed medicines correctly. However, people and relatives did not raise any concerns about the way medicines were administered. A relative said, “I am here every day and I know what is happening, think medication is good as I have not been told of any missed.”

Staff had received training and had their competency checked prior to administration of medicines. Only qualified staff administered medicines. Qualified staff we spoke with told us there was some issues with the ordering and supply of medicines. They told us, “We have a few issues where we have so many shortfalls of medicines, we are spending a lot of time sorting this out. With all the different managers in and out this is still a concern. If we have shortfalls, we keep chasing all the time to make sure people have their medicines. Hopefully the new deputy (Clinical lead) will get these issues sorted.” During the assessment we observed staff administering medicines safely and responded appropriately to requests for pain relief.”

The system for checking and auditing the administration of medicines was not effective. We identified the physical count of medicines did not reconcile with the electronic medicine system. This meant we were not assured people were receiving their medicines as prescribed. We requested the medicines audits completed at the service and we were provided with observations of care and medication core audits. These audits did not identify the concerns found with the reconciliation of medicines nor did they ask the auditor to reconcile medicines.