Oakdene Nursing 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

We found 2 breaches of the legal regulations in relation to safe care and treatment, risks mitigation, governance and management oversight of the service to monitor quality and safety. We were not assured the culture of safety and learning based on openness, transparency and learning from events that have either put people and staff at risk of harm, or that have caused them harm was fully embedded in the service. The provider identified risks to people’s health, safety and welfare for example, risks associated with people’s mobility, swallowing difficulties and malnutrition. However, they were not always mitigated effectively and following best practice guidance. Relevant health and safety concerns were not always included in people’s care plans. For example, medicines support levels and risks were recorded, however these were not in place, or mentioned in the policy, for all high-risk medication, to show that these risks had been considered for each person. We were not assured appropriate support was in place to support and enable staff to prevent avoidable harm. Care plans were not always clear and concise and did not provide comprehensive and sufficient guidance to staff to keep people safe. Staff did not always feel supported by the management and the organisation. We were not assured provider deployed sufficient number of staff to meet people’s needs. However, the provider established effective systems, processes and practices to ensure people were protected from abuse and neglect. Staff and people were supported to understand safeguarding, what being safe means, and how to raise concerns when they don’t feel safe, or they have concerns about the safety of people. There were effective and fully embedded processes for assessing the risk of, preventing, detecting and controlling the spread of infections.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and their relatives felt confident to raise concerns, felt they were listened to, and believed actions would follow. One person told us: “I don't find night staff generally very friendly. I like things just so and they don’t like that. They do things their way and I don’t like it, it's not good enough for me. I told the manager, and they swapped night staff over.” Relatives told us: “Yes totally, I always feel listened to without a shadow of a doubt; always an open door and a sympathetic ear”, “I would go to the deputy manager, and [they] definitely listen to any concerns. I don’t have any at the moment” and “I would phone the care home manager, but I don’t have any concerns. One day I did notice [my loved one’s] hair was greasy and I spoke to them, and they explained [my loved one] had refused to wash it; but they encourage and help [them] to get washed.” We received positive feedback from people and relatives about learning from the events that put people and staff at risk of harm, or that have caused harm. One person told us: “Couple of days ago I found another resident asleep in my bed. I told staff and they were good. They changed bedding for me. They told management and it's been sorted.” One relative commented: “They are very good in the home; I have no worries so far. [My loved one] did have a fall when [they] first moved in and was in hospital for a week. Since [their] return [they] are walking with a frame, and [they] are listening to music in the garden with other residents.”

Staff did not always feel encouraged and supported to raise concerns with the management team. They did not always feel confident that they would be treated with compassion and understanding, and would not be blamed, or treated negatively if they dido so. Staff told us: “There is always a witch hunt against everybody who says something which doesn’t conform to [managers’ names] opinion. Their official answer is: "you cannot talk about it here" or " the door is open, and you can find another job, if you like” and “[Manager’s name] have no respect for any staff member. Nobody can talk to [them] about anything because [they] will just aggressively give orders.”

The culture of safety and learning based on openness, transparency and learning from events that had either put people and staff at risk of harm, or that had caused them harm was not fully embedded. Staff were not actively encouraged to raise concerns and did not always feel confident to do so without being blamed or treated negatively if they did so. Incidents and accidents records were completed. However, they were not always reviewed and scrutinised following best practice guidance. For example, monthly quality audits of incidents and accidents were completed but had not identified where patterns of incidents may have been related to staffing levels. Incidents and accidents analysis sometimes identified staffing absence for individual incidents, but the trends hadn’t been identified or acted upon. We were not assured that learning from accidents and incidents had been effectively shared with the whole staff team or that care plans and risk assessments had always been updated to reflect new learning, or ways to mitigate risk and promote safe, person-centred support.

We received mixed feedback from people and their relatives about maintaining continuity of care and their involvement in creating and reviewing people’s care records. One person told us: “They have done that in the past. They don't ask me every day.” Relatives commented: “There have never been regular reviews”, “On admission to the home I completed a number of questionnaires and spoke with the management team. I have not seen a care plan or been involved in any review processes. However, to be fair I haven't asked to do this, and I believe the home managers would be responsive if I did” and “I am aware of [my loved one’s] care plan and I am involved in reviewing [their] care plan. In the past perhaps not so but this has improved recently.”

Management told us: “We established good rapport with 2 visiting paramedics from local GP surgery. We have regular weekly multidisciplinary meetings with them. We have difficult relationship with 1 or 2 district nurses, they do not share information with staff but then go out and raise safeguarding. We have a meeting with district nurses’ team to discuss working relationship. For example, pressure ulcer was reported by the nurse to the local safeguarding team, but district nurse told staff it was a dry scab and no action” and “There were some historic communication issues that created a breakdown in relationship with home and district nurses’ service. I will be reaching out to the district nurses lead, as there are things I could report to safeguarding like when they said someone's dressing needed changing twice a week but it got to day 6 and they hadn't been. I thought this was a simple case of maybe it had been recorded incorrectly on the system as weekly and you know I was right. I could have raised a safeguarding, but I didn’t because I'm trying to build our relationship". We advised the management they had responsibility to make a referral to the local authority safeguarding team if they felt that neglect occurred.

We received mixed feedback from health and social care professionals. Comments included: “They have staffing issues, there's not always someone to talk to, there's not always a clinical lead in. I avoid contacting or coming in, in the mornings as there is no one really to speak to”, “On arrival at times there is no staff at the reception desk of Oakdene Lodge, and you can be waiting a long time for any staff to appear even if you have booked. With the same happening at Acorn Lodge also, with few staff members being present and corridors appearing very quiet and communal areas with residents or staff. When I have visited at times in the past staff will see me from the office but will not come to question me on if I am ok, who I am, do I need to speak to anyone” and “I had contact with the management team in person, by email and on the telephone. On all occasions, I felt the team were responsive, instructions were carried out and safe practice was observed. Being visible, the management team appeared to have good oversight of the patients’ needs and were able to direct me to senior carers to further communicate with.”

We were not assured provider established effective processes of safety and continuity of care through a collaborative, joined-up approach to safety that involved people in their care along with staff and other partners. We were not assured care and support was always planned and organised with people, together with partners and communities in ways that ensured continuity. Processes to gather the views of people who use services, partners and staff were not always effective and their views not always taken into account. Residents and relatives survey completed in April 2024 did not reflect findings of this inspection. People and their relatives told us they were not always involved in planning and organising their care.

People and their relatives told us they felt Oakdene Nursing Home was a safe place to be. One person told us: “I feel safe here. They will arrange for a doctor if I need one. Most of the time I am happy here.” Relatives commented: “[My loved one] is safe as far as security. I would say, with dementia there is some altercations with other residents and that would be due to staffing but on the whole [they] are safe”, “[My loved one] is safe here. I know because [they] would tell us if anything was wrong”, “I would report all concerns directly to the manager or deputy manager and I believe they would listen and action as appropriate” and “I have no concerns in relation to [my loved one’s] safety.”

Staff had received safeguarding training. They were able to tell us how to recognise the signs and symptoms of abuse and who they would report concerns to both internally and externally. Staff told us: “If ever there were any safeguarding issues that I became aware of I wouldn't hesitate to report it to [the manager], and I know that it would be dealt with properly”, “I would report any concerns to the home manager and/or the deputy managers. I could also call the safeguarding number, which is kept in the nurse's office” and “I would take this to [the manager], or above where necessary. If I felt like this wasn't being taken seriously, I would go outside of the home, to somewhere such as the CQC.”

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. During our SOFI, we observed staff were not present in the communal areas of the dementia unit on number of occasions during day 1 of inspection. We observed altercation between people when we arrived at the communal lounge. Staff were not present. However, a staff member arrived from the corridor and redirected one of the people. We were not assured there were adequate staffing levels to enable staff appropriate risk mitigation and prevention of potential abuse . We observed staffing levels were not always appropriate to make sure people receive consistently safe, good quality care that meets their needs. Staff demonstrated they understood their roles and associated responsibilities. We observed people appeared relaxed and at ease when being supported by staff.

Provider established systems, processes and practices to ensure people were protected from abuse and improper treatment. The home had a safeguarding policy in place and was fully engaged with local safeguarding systems. There were effective systems and processes to investigate, immediately upon becoming aware of, any allegation or evidence of abuse and neglect. The service had policies and procedures about upholding people's rights and making sure diverse needs are respected and met. Staff received training and demonstrated strong understanding of safeguarding and how to take appropriate action. People were supported to raise concerns when they didn’t feel safe, or they had concerns about the safety of others.

People told us they did not always feel involved. Most relatives including people’s legal representatives, told us they are currently not involved in creating and reviewing people’s care plans. Comments included: “[My loved one] did not have too many issues but [they] were wheelchair bound. At first, [they] had an electric chair but that was taken away because [they] would whiz around and cause problems. Now [they] are assisted”, “The cares need to have more specific instruction with regards to my [loved one’s] particular needs and [their] likes and dislikes. For example, the call bell and other items like TV remote are not always put in easy reach; [my loved one] likes [their] tea in a certain way which not all people understand” and “They have always been careful to make sure [my loved one] has a walking aid. Now [they] are bed ridden most of the time and they have put a sensor mat by [their] bed and cot rails to keep [them] safe; so, they react to whether needs are”. Professionals told us: “People are left wandering around with no staff present or left in their rooms. There is not a positive, warm feeling of people around to ensure people feel part of the care home. I feel residents are not able to receive fresh air whenever weather is bad (autumn/winter months) but just going for a walk in the garden with a coat on a cold day would still benefit residents” and “I visit residents at Oakdene frequently. Often when I go to people's bedrooms drinks and call bells are on the table but not in people’s reach, so I move the table closer to them.”

Staff told us they did not always have enough information about people’s support needs and how to mitigate risks people faced every day to keep them safe. Staff were not always able to be involved in creation and update of people’s care plans. Staff told us: “We do have information about people’s needs, but we don't have time to answer the call bell and to attend residents all the time they need”, “I am not updated on the food level changes when residents' requirements change. Or when we have new residents” and “We always make everyone feel at home and included with everything. We encourage everyone to join in different things around the home like activities and entertainment.”

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. During our SOFI, we observed people were able to move around the house and grounds freely during day one and day two of the inspection. We observed 1 person moving around with or without their walking aid and staff were not prompting them to use it. We reviewed their records and found inconsistencies and conflicting information in this person’s care plan regarding support they needed to mobilise safely. We observed another person was consistently using keys to lock and unlock their bedroom door during inspection. We reviewed their records, which stated they didn’t have access to their bedroom key because they would lock themselves in their room, which would not be safe for their wellbeing. This meant risks to people’s health and safety were not effectively mitigated which put them at increased risk of avoidable harm.

People’s risks were assessed before they started to use the service and added to as needed. Risk assessments were created and maintained within the provider paper-based care planning system. Assessments were updated regularly and as things changed. However, some assessments contained conflicting information within them. We were not assured provider always identified and mitigated risks to people’s health, safety and welfare effectively and following best practice guidance. Relevant health and safety concerns were not always included in people’s care plans . For example, medicines support levels and risks were recorded, however these were not in place, or mentioned in the policy, for all high-risk medication, to show that these risks had been considered for each person. We were not assured appropriate support and guidance was in place to support and enable staff to prevent avoidable harm. Care plans were not always clear and consistent, some contained conflicting and contradictory information and did not provide sufficient guidance for staff to keep people safe. The provider identified risks to people’s health, safety and welfare for example, risks associated with people’s mobility, swallowing difficulties and malnutrition. However, they were not always mitigated effectively and following best practice guidance.

People told us they liked recent changes and improvements to make the environment more dementia friendly. One relative told us: “Although Acorn Lodge is purpose built with its design appropriate for my [loved one], I feel 'at home' when I'm with [them]. The layout and design of the lounge, for example, has a calm and relaxed feel and thus is comfortable to sit in; not least when friends/relatives make only occasional visits.” Others commented: “I think the dining room lacks a bit of attention at times. They just changed all the chairs and I have sat in a chair with piddle before. But it has improved now 100%. I think the maintenance man is really good and also good with the residents as well” and “The cleaners are good, and the handy man keeps the place quite well maintained. I have a good relationship with the staff and feel able to approach them with anything.”

The manager told us: “Lots of improvement works were made to Acorn Lodge’s environment to made it more dementia friendly. Ladies living in Oakdene Lodge really liked what we've done and wanted seme improvements what dementia had so we had to same for them like destination boards, train cabin and waiting room, therapy dols and cats in Oakdene Lodge too.” Staff commented: “It is nice that relatives have noticed good changes to Acorn Lodge to with more dementia friendly things like the boutique and the atmosphere is much nicer” and “We all did virtual dementia bus training. It opened my eyes on how people with dementia feel and inspired how to make changes for the residents. It became my passion project. It helps to get people involved one wipes tables and another used a paint roller to paint dining room."

The home was being redecorated. The provider followed good practice guidance to assess how each person living with dementia could orientate themselves in their surroundings. Contrasting colours and clear signage had been used. People had personalised items to easily identify which room was theirs. We observed breakout spaces and destination boards, train cabin room and waiting room, tea shop area, boutique room with clothes to dress up. People and their relatives were able to personalise their bedroom to reflect their lifestyle choices, interests, and hobbies. People moved around freely, spending time as they pleased within the home. The garden was accessible.

People were cared for in safe environments that were designed to meet their needs. Facilities, equipment and technology were well-maintained and consistently supported staff to deliver safe and effective care. There were effective arrangements to monitor the safety and upkeep of the premises. Equipment used to deliver care and treatment were suitable for the intended purpose, maintained and stored securely and used properly. Leaders and staff considered how environments could keep people safe from psychological harm as well as physical harm, for example in relation to sensory needs.

People were not always supported by sufficient numbers of staff to meet their needs. Some people told us staff did not always answer the call bell in a timely manner. People told us: “Sometimes I need to wait when I press the call bell when staff are busy. I cannot be attended to just because I want to, I need to take others into consideration. Took me long time to get used to that” and “Staff don't come straight away when I press the bell. They don’t have enough staff.” Relatives agreed: “Call bells are ringing out all the time when I visit [my loved one]. When I want to leave the home, I have to wait at least 10 minutes for a member of staff to appear to open the door for me.” People and their relatives told us there had been a high turnover of staff and management. Comments included: “There has been a high turnover in the recent years which means staff don’t get to know my [loved one]”, “There has been quite a lot of turnover of staff, which I know is not unusual in the care sector, but I have always felt [my loved one] has been looked after well and [they] appreciate this” and “It’s hard to comment, as the management has changed several times since 2021 when [my loved one] came to Oakdene, and the recent manager has only just started.”

Staff told us they did not feel staffing levels were always sufficient. Comments from staff included: “We don't have enough time to feed people who need support in bed, we do what we can, and we run all the time. People lose weight, we notice, we don't have time to prepare a cup of tea. We encourage drinks, mostly in summer, but it is not enough”, “There isn't enough staff working at the home and residents don't always get the care and the interaction that they need. One resident has mentioned how they weren't happy with their morning routine of being washed and dressed. Also, how they are having to wait a long time to have someone to come and see them when they are in need of a carer. They have had this issue on multiple occasions all due to not having enough carers to be able to fulfil the needs for the residents” and “I strongly believe we do not have enough staff in all departments. Residents notice this as well. Especially care staff struggle when it comes to meeting the care needs. Most of the time there is 2 members of staff in a building caring for 26 dementia residents with one acting senior, which won’t always be able to help as they have tons of paperwork to do.” Staff did not always feel supported and appreciated by the management. Comments included: “Unfortunately I find that [name] does not make staff feel valued at all and can be very rude, abrupt in [their] ways of speaking. I love to empower and make staff feel valued and wanted, this then makes for a happy workplace in my opinion”, “I don't feel appreciated by the managers at all. I only feel appreciated by the residents and their families” and “I feel as a home we all help one another as much as possible but get no respect or validation back from higher above.”

During our SOFI, we observed most people appeared relaxed and at ease when supported by staff. Staff knew people's non-verbal and behaviour cues, offering reassurance and distraction techniques to defuse escalating conflict between people. However, there was not always adequate staffing in the communal areas to meet the needs of people using the service. We observed altercations between 2 people in the evening during day 1 of the inspection when staff were not present. We observed 1 person in distress being ignored by a member of staff who walked away with no obvious attempts to de-escalate the situation. That person later left the communal area unsupported. We raised this with the manager who told us staff were following person’s care plan. The person's records demonstrated they had experienced frequent episodes of distress. However, the person’s care plan in place did not provide clear and consistent guidance for staff on known triggers, and ways to safely support the person when they were in an agitated state.

The provider did not deploy sufficient numbers of staff to make sure they could meet people’s needs and keep them safe at all times. Processes were in place to determine adequate number of staff and range of skills and competence. The provider told us they used a dependency tool which calculated the number of staff needed. However, this was not effective to respond to the changing needs and circumstances of people using the service. People were supported by staff that had been recruited safely. Safe recruitment requires staff to follow an application process including assessment of their history, character, and qualifications to ensure they are suitable to work with people. The manager told us they recently recruited new staff and had no vacancies. All staff files viewed contained a valid DBS check. Disclosure and Barring Service (DBS) checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Staff had access to training identified as necessary to meet people’s needs. There was evidence of observation and competency checks.

People and their relatives told us the home was clean and well maintained. People told us: “The home is kept clean, every day” and “Clean and well maintained, to a point. There are people here cleaning all the time.” Relatives agreed: “I think they were doing a sterling job, there were not so areas clean at certain points in time, it was always a reactive thing, when things happened. But now they do seem on top of it all”, “Oh it’s spotless, its lovely and clean” and “I would say very clean, they just had new furniture all through and they keep it well maintained.”

Housekeeping staff told us they conducted daily cleaning schedules and checks to ensure processes were being followed and all areas were being cleaned. These included daily disinfection of contact surfaces such as rails, door handles, light switches, and keypads. Staff told us: “We have daily checklists to go through in all the bedrooms and all the communal areas. And the end of each week all cleaning schedules are being reviewed”, “One cleaner is responsible for bedrooms in each lodge and 1 is responsible for communal areas in both lodges. We only have 1 laundry assistant for both lodges which is difficult. Sometimes communal cleaner helps with the laundry” and “Following pandemic we have abundance of mask, surplus of aprons and visors. We do regular stock checks which include expiry dates on all personal protective equipment (PPE ).”

We observed the service was clean and free from odours. During the site visit we saw cleaning taking place. PPE was available throughout the service, and we observed staff using PPE safely and appropriately. Compliance with the infection control policy was observed during daily Infection Prevention and Control (IPC) monitoring checks conducted by the manager at daily walkarounds, where staff demonstrated how to work in a safe and clean way.

Infection prevention and control was at the core of the service and staff had received training with regular updates. Due to the global pandemic in recent years infection prevention had become more in depth, training and procedures were more robust. Staff were more aware of the importance of cleanliness and hygiene. Cleaning records demonstrated what was being cleaned. Managers at the service had oversight of infection prevention and control (IPC) and carried out regular audits and checks of all aspects of infection control. The provider’s IPC policy was up to date. Infection prevention and control procedures were robust, in line with the providers policy. At the time of the inspection there were no restrictions for relatives and loved ones to visit people living at Oakdene Nursing Home. There were currently no people with Covid in the service.

People told us they their medicines in a kind and caring way, and as prescribed for them. People’s individual preferences for how they liked to take their medicines were considered. One person told us: “I’m happy with how [staff] give me my medicines. I get them at the right times. I have tablets, ear drops and eye drops. I have glaucoma and I am really worried I will go blind at some point.” Relatives commented: “Medication is always administered on time. I am more aware of changes to [my loved one's] medication recently, this was possibly an improvement over the past year”, “I do know what [my loved one] is taking. They do discuss it with me, and they discuss new prescriptions with me. As far as I am aware, [my loved one] gets it when [they] should” and “I have been visiting when [my loved one’s] medication has been given. I have also given permission for repeat prescriptions to be dealt with directly by the home without being authorised by myself. I have no concerns and feel that everything is in order.” While the people we spoke to expressed that they were generally happy with support with their medicines, our assessment found medicines management and oversight did not meet the expected standards.

Staff told us they felt well supported regarding medicines management, and that they felt that the systems in place worked well. They told us they had training and competency checks to make sure they gave medicines safely. They were able to describe how medicines errors or incidents were recorded and followed-up. Comments from staff include: “I have all the training and good support from the manager to support residents with medication” and “We have sufficient number of trained staff and don’t need agency staff for giving medicines.”

Audits and quality checks to ensure the proper and safe management of medicines were not always effective. Quality checks had not identified or addressed that staff were not following policy with regard to fridge temperature resetting recording or in relation to the risks associated with the administration of blood thinning medication. Medicines support levels and risks were recorded, however these were not mentioned in the policy, for flammable topical preparations, to show that these risks had been considered for each person. People’s medicines were stored securely, and medicines errors or incidents were reported and investigated. Medicines records showed that they were given as prescribed for people, and personalised protocols were in place for medicines prescribed ‘when required’. We observed staff giving medicines safely and in a kind and caring way, taking time with people, and asking if any ‘when required’ medicines were required. We observed people’s individual preferences for how they liked to take their medicines were respected by staff.