Date of assessment: 20 June to 09 July 2024. This assessment was carried out in response to information we had received about the service. We reviewed 11 quality statements under the key questions of safe, effective and well led. People were supported to remain safe. The provider had policies and procedures in place for safeguarding to protect people from the risk of abuse. Staff understood their responsibilities to keep people safe. Staff were recruited safely and the environment and equipment were well maintained. The provider ensured learning was shared with staff at regular meetings. However, improvements were required to ensure timely actions were taken when issues were identified and that there was effective oversight of delegated tasks. Risks associated with people’s health conditions were not always recorded, which meant staff did not always have information to guide them in providing the correct support. Further work was required to embed the principles of the Mental Capacity Act (MCA). Staff were not always effectively deployed. We identified a breach of regulation in relation to governance. We have asked the provider for an action plan in response to the concerns found at this assessment.
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The Oaks received an overall Good rating following a focused inspection of Safe and Well-Led only, with Well-Led downgraded to Requires Improvement due to management instability, the absence of a registered manager, and shortfalls in care planning documentation and safeguarding oversight. The provider was taking proactive steps to address these issues, including external management support and detailed improvement plans.
Concerns (6)
criticalLeadership: “At the time of our inspection there was not a registered manager in post.”
moderateCare planning: “people who were at risk of pressure area care had no care plans in place to inform staff how to manage the risks.”
moderateRecord keeping: “Records relating to the administration of 'as and when' required [PRN] medicines were not always in place.”
moderateGovernance: “A number of changes in the management structure had impacted on the oversight of the service and staff morale.”
moderateSafeguarding: “The provider had identified shortfalls with documentation and safeguarding at the service and was taking appropriate action to address this.”
moderateMedication management: “Systems in place to monitor the management of medication had identified concerns relating to the PRN documentation, stock control and missed administration of medicines.”
Strengths
· Medicines were stored, recorded and administered safely, with staff competency checks in place.
The Oaks was rated Good across all five key questions, with significant improvements made under the new provider since the previous Requires Improvement rating, addressing prior breaches of regulations 12 and 17. Minor concerns remained around staffing levels feedback from people and some incomplete recruitment checks, both of which the provider was actively addressing.
Concerns (3)
minorStaffing levels: “There is a shortage of staff, we definitely need more staff, but they all work very hard.”
minorStaffing levels: “The demands on the staff mean they can't come straight away, but they come as soon as they can.”
minorOther: “Some staff did not have all the essential checks completed and the provider recognised this.”
Strengths
· Safe management of medicines using an electronic medication system with oversight and competency checks
· Established systems and processes to safeguard people from abuse and neglect
· Robust risk assessments and routine environmental safety checks
· Effective infection prevention and control measures including PPE, testing and visiting arrangements
· Strong culture of lessons learnt with monitoring of accidents, incidents and trends
Quality-Statement breakdown (26)
safe: Using medicines safelyNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Staffing and recruitmentNot rated
safe: Preventing and controlling infectionNot rated
safe: Visiting in care homesNot rated
safe: Learning lessons when things go wrongNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Staff support: induction, training, skills and experienceNot rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Staff working with other agencies and supporting people to access healthcareNot rated
effective: Adapting service, design, decoration to meet people's needsNot rated
caring: Ensuring people are well treated and supported; respecting equality, diversity, privacy, dignity and independenceNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot rated
responsive: Meeting people's communication needsNot rated
responsive: Supporting people to develop and maintain relationships and take part in activitiesNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: End of life care and supportNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: Duty of candourNot rated
well-led: Managers and staff being clear about their roles and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Continuous learning and improving careNot rated
well-led: Working in partnership with othersNot rated