Oak Farm

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

During our assessment of this key question, we found concerns relating to the management of medicines and of safeguarding. These concerns constituted breaches of Regulations 12 and 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below. We identified concerns with the security of medicines, dating and labelling of medicines, family medicines being administered without prescription or GP agreement, failure to risk assess homeopathic medicines and inaccurate stock control and auditing. Individual staff were clear about their safeguarding responsibilities, but the provider needed more robust systems regarding the use of volunteers and sub-contractors. Risks were mostly well managed, but some staff were unclear on fire procedures. The environment itself was not fully secure which placed people and their possessions at risk. Staffing was mostly in line with the service’s dependency tool but deployment of staff did not always ensure staff could be easily located. Staff were safely recruited and received good training and ongoing support.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us they experienced safe care and felt staff were well trained. They felt able to raise matters relating to their safe care and treatment. People told us staff would listen to them and respond. Relatives told us they were informed about any safety issues which affected their family member and action was taken.

Staff were clear about their responsibility to provide safe care and knew how to manage and record safety incidents such as falls. Staff assured us key safety information was included in handovers from shift to shift and records confirmed this.

Accidents, incidents and near misses were recorded and audited monthly. The registered manager told us this information was then shared with the provider but there were no audits signed off themselves by regional leaders. We saw action had followed where a risk had been identified. For example, we noted an accident report relating to some shelves which a person had hit their head on. The record stated the shelves were to be removed and we found this had been actioned promptly.

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 who used the service told us they felt safe. They said they trusted the staff to raise concerns on their behalf if they needed to.

Staff received safeguarding training, although some were overdue for refresher training, according to the provider's own schedule, and some had no record of this training. Induction for new staff contained safeguarding training and information was available to guide staff on how to raise concerns. Staff demonstrated they understood their responsibility to raise safeguarding concerns and knew how to do this both within the service and externally. The registered manager and regional leaders acted quickly to address our concerns relating to the safe employment of volunteers.

Staff understood how to spot the signs and symptoms which might indicate a person was being abused and understood how to escalate concerns if needed.

The provider had made appropriate safeguarding referrals to the local authority and informed the Care Quality Commission when safeguarding concerns were being investigated. However, we noted a lack of robust safeguarding procedures relating to volunteers and sub-contractors. On our evening visit a person was present and accessing the service late into the night with no staff member in attendance. We were informed by the registered manager that this person was a volunteer, although we were informed later they were in fact a sub-contractor. The person had been vetted by the Disclosure and Barring Service some years ago and had been previously employed by the organisation. There was no risk assessment in place which was specific to this person and no additional information available about them when we requested it onsite. The registered manager was unaware of a volunteer policy, although the provider did have one which they sent to us following our onsite visit. The risk assessment relating to volunteers was generic and the provider reviewed this thoroughly after our visit. The new risk assessment stated staff should be in attendance with volunteers and sub-contractors should they need to enter a resident’s bedroom and procedures were reviewed overall. The service was not operating in line with an effective volunteer or sub-contractor risk assessment or its own policy at the time of our onsite visit. This meant people who used the service were placed at an increased risk. This constituted a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People told us they were supported to manage risks and had confidence in the staff. Relatives fed back positively about how the service helped reduce and manage a variety of risks. For example, one person told us, ‘My relative is moved every 2 hours. They did have a bed sore on leaving [hospital]….now their skin integrity is fine.’ Most people were involved in reviews of their care and support needs relating to risk but 4 relatives stated they had not always been asked about specific risks and 2 people who used the service told us they did not feel they were fully supported with risk management.

Staff were clear about risks relating to people's health and care and knew where to find information about specific risks. Healthcare professionals worked with staff to reduce risks for people and feedback was positive. One healthcare professional felt staff could be more proactive once they had identified a concern and begin to address it more promptly. They commented, 'Generally, all advice is acted on, and they are very good at identifying residents whose MUST scores are high, though they may not have always put in place fortified diets'. People whose MUST (Malnutrition Universal Screening Tool) scores are high are identified as being at risk of not eating enough.

People whose liberty had been restricted under the Deprivation of Liberty Safeguards were exposed to additional risk as the service was not fully secure. Staffing was found to be lower at night which meant this risk increased and had not been well managed. Other risks, such as those relating to choking, diabetes, falls and pressure care were well managed and we observed staff supporting people safely to reduce these.

Risks were mostly well documented and measures to reduce risk clearly outlined. Records of people’s repositioning were completed but oversight of these records was difficult due to computer issues which meant it was not always possible to establish the exact times people had been repositioned. The provider told us they would be trialling a new system to reduce this particular concern.

Most people told us they felt the environment was safe for them to use and nobody expressed significant concerns. People’s bedrooms were well maintained and there was an accessible outside space for people to use. One person was concerned as the smoking area was close to their bedroom and staff often left their window open and they were unable to close it themselves. They also expressed concerns about the security of their bedroom as the window was open at night and they were on the ground floor.

Staff showed an understanding of how to ensure the environment was kept safe ensuring there were no trip hazards or unsafe equipment in use. Staff who had the responsibility for carrying out health and safety checks of the environment did so in accordance with an agreed schedule. Not all staff demonstrated a clear understanding of the fire procedures. We fed this back to the provider who agreed to take action to address this.

The environment was mostly well maintained, although some aspects needed addressing. A disused metal bedframe was propped up in the smoking area. We noted this smoking area was very close to bedrooms where all the windows were wide open due to the hot weather. This meant smoke was drifting into these rooms which was not pleasant or healthy for the occupants. On our evening site visit we noted the environment was not secure as multiple doors and windows were open. The door to the smoking area was propped open and allowed access from the driveway. We also noted the insecurity of the front door when we carried out our night visit. We were able to let ourselves into the lobby and a person who used the service was easily able to open the main door and let us in not knowing who we were. No staff were present in this area for 10 minutes. This lack of security placed people and their property at potential risk. The provider told us they were taking steps to address this. The environment was suited to the people who used the service with wide corridors, appropriate signage and hoists and mobility aids to support people. The gym was well used by people and was well equipped, with bariatric equipment for people of a greater weight.

There were processes in place to check the safety and security of the service. Records relating to the testing of fire and emergency lighting systems were difficult to navigate as some were in different places and in different formats. It was not always easy to establish if repairs had taken place promptly when faults were identified. However, systems were in place and ultimately records supplied to us did document equipment was monitored and maintained safely. However, auditing processes had not identified the issues with the security of the environment we found on our evening site visit.

Feedback about the staff was mostly positive from people who used the service and relatives and staffing levels were considered appropriate. One relative commented, ‘My relative is safe and well. Safe enough for me to go away for 2 weeks with my family.’ Another said, ‘The staff understand my relative’s needs.’ Some people who used the service expressed a desire to do more in the evenings but staffing levels would not allow this. One person told us, 'The staff are nice but they are not always easy to find.'

Staff told us they had the training they needed to carry out their roles. We found staff to be skilled and nurses and senior staff had a good understanding or people’s needs and health conditions. However, staff understanding in some areas, including fire, people’s capacity to consent to their care and the laws relating to depriving people of their liberty were not fully understood by all staff, including more senior staff, despite the training they had received. Staff received supervision and support from their line manager and records confirmed this. Staff told us there was an effective handover in place between shifts to ensure people's current care and support needs were clear to all staff.

During our daytime visit we noted there were enough skilled staff deployed to meet people’s needs promptly. Staff, including physiotherapists and occupational therapists were available to meet people’s specific needs. However, day staff handed over to night staff at 7pm and numbers reduced significantly. We carried out an unannounced evening visit and found the main lights to communal areas of the building had been turned off at 19.45. We found 22 of the 26 people in the main building were in bed by 20.00. Several of them told us this was not their choice. There were four staff on duty including one nurse and one care assistant in the Lodge, which is a separate unit. The nurse was observed leaving the service to administer medicines to another of the provider's services on the same site. We were let into the building by one of the people who use the service, and we were unable to locate any staff member for several minutes. The person who let us in commented, ‘I think they’ve all gone home.’ This meant staffing levels did not always support people’s choices and did not ensure their safety.

The rota was designed to ensure staff were suitably deployed. Although rotas showed staffing broadly in line with the dependency tool the service used, it didn’t reflect how the nurse was routinely shared with another service. The provider assured us measures were in place to alert the nurse to return, should an emergency occur. Staff were safely recruited, including those who had come from overseas via the government sponsorship scheme. Induction was comprehensive and new staff were well supported. Staff received a variety of relevant training, although some refresher training was overdue for some staff, according to the records supplied to us. Nurses underwent a process of revalidation of their nursing PIN to ensure they maintained their nursing registration with the Nursing and Midwifery Council.

People who used the service were happy with the cleanliness of their rooms and common areas. Relatives also gave positive feeedback with one commenting, 'Everywhere is clean and it's highly improved over the last 3 years.'

Staff were clear about their responsibility to maintain a clean environment to minimise the risk of infection.

The service appeared clean and well maintained. Staff infection control practices were found to be good during their interactions with people who used the service. We did observe one member of staff wearing a mask, but not in accordance with infection control processes and we could not understand the reason for it. However, the therapy kitchen contained some items which were heavily stained and needed replacing. There was also some unlabelled and out of date foods stored. We fed back our observations about areas of the therapy kitchen to the registered manager. They accepted our feedback and took prompt action to address it by introducing new systems and replacing some items.

Comprehensive cleaning schedules were in place and were monitored by senior staff. The risk of legionella bacteria was monitored and reduced by regular testing by an external company. The registered manager carried out a weekly audit and we saw some concerns had been identified relating to the cleanliness of PEG sites. PEG (percutaneous enteral gastronomy) is used to introduce foods directly to the person via a tube. Concerns had been followed up and the same issues did not keep recurring. However, we found processes did not identify some of the issues we found relating to a person’s own fridge and general cleanliness of the therapy kitchen.

Most people told us they were happy with the way they received their medicines. One person was not happy about being unable to access their own topical cream as it was left on the far side of the room. Records did not evidence this person had been risk assessed to manage this medicine themselves. We observed nurses administering people’s medicines. Nurses were not rushed, had a very caring manner and took time to explain what each medicine was for.

Despite training, staff were not sufficiently clear about who had covert medicines in place. These are medicines given to a person without their knowledge following an assessment of their capacity to consent. Nursing staff gave us differing names when we asked who had this measure authorised. Staff were also unclear about some people’s current suitability to take homely remedies, such as cough syrup, and the safety of mixing homeopathic and standard medicines. One care staff member was unclear about whether a person could or could not administer their own topical cream. The person told us they could not always reach this medicine. The staff member stated the person’s medicine should be locked away as it was prescribed and for the safety of others. It was not locked away but was also not accessible to the person either.

Although medicines were kept in locked cupboards in the locked medicines room, the security of medicines was not sufficiently robust. When we carried out our evening visit, we noted the large window into the medicines room, which was next to the front door, was completely open. Processes relating to homely medicines, such as indigestion remedies,, were not safe as they had not been reviewed to ensure they were safe for all residents to take. One person had their own stock of homeopathic medicines which they self-administered. Processes relating to this were not robust. A risk assessment for one homeopathic medicine was not being followed by the service and information for staff was not clear. There was limited evidence to show these medicines had been assessed as safe to take with the standard medicine this person was taking. Another person’s family had brought in over the counter anti-allergy medicines which were not recorded on the person’s medication administration record. The registered manager told us this person had previously had this medicine prescribed but there were no records relating to this, no assessment of the current safety of the medicine for this person and no effective stock control was in place. Stock control and auditing procedures were not robust. We found out of date medicines, unlabelled medicines and discrepancies in stock numbers. We also found processes relating to the administration of covert medicines needed review. This meant we could not be assured medicines were managed safely which constituted a breach of Regulation 12. Since our onsite visit the provider has addressed our concerns and told us they have introduced more robust systems.