Corner Oaks

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 service since they registered. This key question has been rated requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 50 (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 did not have a proactive and positive culture of safety based on openness and honesty. Leaders did not act on concerns about safety and did not investigate and report safety events. Lessons were not learnt to continually identify and embed good practice.

There was a lack of reporting systems in place to ensure risk and adverse incidents were reported to external stakeholders, including the Local Authority and to CQC. This did not ensure people were protected from the risk of harm. Leaders were not reviewing and reflecting on events within the service to reduce the risk of reoccurrence.

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

No one living at the service was a recent admission. We could see examples of pre-admission assessments completed prior to people moving in, and these considered the needs and dynamics of the existing household. We observed good communication between the service and external agencies, including where people attended community resources including education. People were encouraged to meet inspectors and share feedback about their lived experiences.

The provider did not work well with external stakeholders to understand what being safe meant and how to achieve that. The provider did not share concerns appropriately with third party stakeholders to protect people’s rights.

Leaders did not understand their regulatory responsibilities to ensure incidents and events happening in the service were appropriately reported to CQC and other stakeholders. The provider submitted retrospective notifications to CQC as an outcome of the inspection and implemented improved monitoring systems to reduce the risk of reoccurrence.

The provider worked collaboratively to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was supportive and enabled people to do the things that mattered to them.

Staff demonstrated consistently detailed knowledge of people’s individual preferences in relation to the delivery of their care and support. People were encouraged to maintain hobbies and personal interests, and we observed staff to use this information to support people to engage in meaningful activities. People told us about what they enjoyed watching on television and showed us belongings of personal value and attachment that they wanted to make sure we had seen while we were at the service.

The provider did not detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Risks in relation to water temperatures exceeding safe ranges, increasing the risk of scalds or injury were known to the provider, identified on their own internal audits and checks but had not been addressed until raised as an outcome of our inspection. People were reliant on staff to pre-empt risks and support them to maintain their safety.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

We identified there was consistently only 2 staff on shift at night time, which would not be sufficient numbers to respond in the event of an emergency such as a fire, due to the level of support each person required. We also identified that only 1 of the 2 staff on shift at night time had completed medicines management training, this did not ensure sufficient numbers of medicines trained staff were on shift at night. People’s relatives told us there had been a period of change within the staff team, which was unsettling, but overall this was felt to have now improved.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was visually clean throughout, with no malodour. Staff completed thorough cleaning as part of their allocated tasks during each shift. Staff had access to cleaning products, and these were stored securely. Staff had access to personal protective equipment, observed to be worn appropriately during our site visits, and accessible to staff in the event of an outbreak. Our findings were reinforced by feedback received from people’s relatives.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

We identified areas of risk in relation to the management of people’s medicines when taking them out in the community; fire safety in relation to flammable creams and ensuring people’s allergy information was accurately recorded. Where a person was receiving their medicines covertly (hidden in food or fluids), the corresponding assessments of their mental capacity and best interest decision had not been completed. We identified as required medicine protocols to be unclear and lacked required levels of detail to ensure safe administration of these medicines. The service were responsive and acted on our feedback as an outcome of the inspection.