Oaklodge Care 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

The registered manager and provider failed to have sufficient systems to ensure the environment was safe. Staff had not received all training required to keep people safe in the event of a fire. The provider had not ensured there was enough staff to meet people’s needs and keep them safe and to maintain the cleanliness of the home and prevent the spread of infections. The provider failed to ensure there was a culture of safety and learning and risks to people were overlooked. Systems and processes had failed to recognise the potential risk of harm to people at risk of malnutrition and dehydration. Records of people’s fluid input showed not all people had been provided with sufficient fluid intake and placed people at risk of dehydration. People did not always have access to their prescribed medicines when needed. People were unable to be given PRN ‘as required’ medication during the night as there were no trained members of staff on shift to do this. Staff administering people’s medicines were confident and knowledgeable about safe medicine practices and procedures. Safeguarding policies and procedures required further review and development. Where safeguarding concerns had been identified, the registered manager reported these to the relevant authorities and conducted investigations where required. There was an understanding of the Deprivation of Liberty Safeguards (DoLS) and this was only used in the best interest of the person.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were at increased risk of falls during the night as the provider had not increased staffing levels, despite this being identified by the registered manager as a change required to improve the safety and care for people. Records showed staff took appropriate action where people had experienced an accident or incident. This included contacting the emergency services for assistance and requests to the GP or other health professional for an assessment or review. Where accident and incidents had occurred, records showed people’s relatives were informed.

Staff told us the registered manager shared information with them about incidents and learning. A staff member said, “[The registered manager] will let us know what to do different, show and guide us.” During the assessment, the registered manager held a meeting with staff to share the concerns found by CQC and address where improvements were required. Further improvement was required to ensure staff were encouraged and supported to raise concerns and identify and manage risks before safety events happen.

The provider failed to ensure there was a culture of safety and learning and risks to people were overlooked. For example, actions identified from the Fire Safety Risk Assessments completed in 2022 and 2023 had not been completed. This placed people at risk of harm. Incident and accident records were reviewed by the registered manager on completion by staff and a monthly analysis was completed to identify themes, patterns and learning. The registered manager had identified an additional night staff was required to reduce the risk of falls people experienced. In January 2024, it was identified that eight of the falls happened when staffing levels were low and the registered manager requested for additional staff to be allocated. This had not been implemented by the provider and placed people at risk of harm. Following our first site visit, we highlighted our concerns with the provider and registered manager who failed to take appropriate and timely action. Safety failings highlighted to the provider and registered manager on our first visit had not been actioned by our second site visit. For example, substances that are hazardous to health, such as cleaning products, were seen to be accessible and unsecured during both site visits.

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 were at risk of experiencing avoidable harm and neglect as staff and leaders did not always recognise risks to people’s safety and well being. Staff were not always available to respond to people in a timely manner. However, people had access to information about safeguarding in an accessible, easy to understand format. People and their relatives had the opportunity to raise concerns about their or other people’s safety. Monthly meetings took place with people and relatives where people were asked if they had any concerns. The registered manager conducted a daily walk around the service which included speaking to people.

Staff had completed training in safeguarding and explained what action they would take should a person experience abuse or neglect. Staff had access to safeguarding policies and procedures. Staff told us they felt confident to raise concerns with the registered manager. The registered manager understood their responsibilities in safeguarding people at the service. However, we were not assured the registered manager and staff would always recognise and report concerns about the safety of people in the service. During the assessment, the service received a visit from the local authority safeguarding team who identified some safeguarding concerns and requested the registered manager completed safeguarding referrals for these. This had not been previously identified or reported by the registered manager or staff.

People with complex needs were alone in the communal lounge or in their rooms for long periods of time without staff being available to support them. Some people were seen to be distressed and required support and reassurance. As well as this, medicine and objects such as scissors and cable ties were accessible to people living with dementia.

The provider had systems and processes in place for safeguarding. However, they required improvement as policies and procedures lacked sufficient detail and had not been reviewed to ensure the information and guidance for staff remained relevant and up to date. Where safeguarding concerns had been identified, the registered manager reported these to the relevant authorities and conducted investigations where required. There was an understanding of the Deprivation of Liberty Safeguards (DoLS) and this was only used in the best interest of the person.

People and their relatives told us staff supported them to keep safe and they had no concerns about the management of identified risks. People’s relatives told us they were informed if their loved one had suffered a fall or had been involved in an incident. People who had been identified as at high risk of falls had sensor equipment in place to alert staff when they started to mobilise to reduce the risk of falls. However, we were not assured the sensor equipment was always on, positioned correctly or checked by staff. For example, one person had been identified as a high risk of falls had a sensor in place at their bedroom door to alert staff to support the person to mobilise safely. However, this person had accessed the stairs to the first floor and experienced a fall without staff noticing. It was later identified the sensor did not activate due to it being positioned incorrectly.

Staff demonstrated they understood people’s risks and how to mitigate these. Staff had access to people’s risk assessments. Staff told us they carried out two hourly checks on every person in the service. However, we were not assured all staff fully understood each person’s identified risks and how to mitigate these. For example, people at high risk of falls were seen to be left unattended and unsupervised of long periods of time. Records showed there had been a high number of falls since January 2024.

During our assessment, we observed a person to be sat at the dining room table, asleep, with their breakfast and drink placed in front of them. The person was sat asleep for 45 minutes until a staff member came to support them, by which time, the breakfast and drink would have become cold. This person was known to be at risk of malnutrition, dehydration and choking. This placed the person at risk of harm. Another person who experienced swallowing difficulties, was seen to have been given a drink by staff without thickening powder added, as required, to reduce the risk of choking. Staff were also observed to give this person medication in a tablet form which they struggled to swallow. Staff told us they had spoken to the GP about this but that particular medicine could not be administered in liquid form. Staff had failed to seek further advice or take additional action to reduce the risk of choking for this person when taking their medicines.

Systems and processes had failed to recognise the potential risk of harm to people at risk of malnutrition and dehydration. Records of people’s fluid input showed not all people had been provided with sufficient fluid intake and placed people at risk of dehydration. People’s care plans did not provide staff with guidance on how much fluid a person should be encouraged to have within a 24-hour period. One person had experienced weight loss and staff failed to seek advice from a relevant healthcare professional. Accidents and incidents had been reviewed and audited by the registered manager. For the audit completed in January 2023, the registered manager had identified most of the falls occurred during reduced staffing hours and sought approval from the provider to add an additional member of staff at night. At the time of the assessment, staffing levels had not increased despite this being identified as a possible contributing factor to increased falls. Risk assessments had been carried out and staff were in the process of changing these from paper to electronic records. However, the registered manager and staff were not familiar or confident in using the electronic system and did not know how to use it to monitor people’s food and fluid intake. People’s care plans lacked detail on how to support people to manage their distress and anxieties, including the potential triggers that could lead to people becoming distressed or anxious, how staff can avoid these triggers and the interventions and approaches staff should use. Observation tools were not completed by staff to help understand the causes of people’s distress or anxiety which may present as challenging, by recording what happened before, during and after the behaviour for this to be monitored and patterns identified.

People were at increased risk of harm due to systems and processes being ineffective in ensuring the environment was safe. For example, substances that were hazardous to health, such as cleaning products, were accessible and unsecured. This increased the risk of harm to people if used or ingested. People’s relatives raised concerns regarding the maintenance of the building and the effect this had on their loved one’s safety and well being. A relative told us, “The maintenance is not good there. For example, the lift is not working and [relative] has to be carried downstairs by paramedics because the stair lift and the lift have not been working. The lift has not worked for the last four weeks and the stair lift has never worked since [relative] has been there.” Another relative said, “The maintenance is slowly going downhill. For example, the lift is out of action and has been since the week before Easter which is now about four weeks ago. The general upkeep of [relative’s] bedroom is in a disgraceful condition and in particular the decor of it. [Relative] has an en-suite bathroom, but this has been used as a general storeroom in the past, though when I visited last week it had been cleared.” Evidence showed the lift broke on 30th March 2024 which was reported by the provider and parts were ordered. On 16 April 2024, the lift was fixed.

Staff had not received all training required to keep people safe in the event of a fire. An evacuation mattress was in place for staff to use in the event of an emergency, such as a fire, to evacuate people out of the building. Staff had not undertaken any training and had not practiced using the evacuation mattress. This placed people at increased risk of harm in the event of a fire. A staff member told us, “Some of the rooms on the top floor although they do have hot water for the showers, they do not have hot water from the taps and during winter months the heating and hot water to rooms can be temperamental causing rooms to be cold even with the use of electric heaters."

We were not assured leaders and staff recognised where the environment posed a potential risk of harm to people. For example, during the assessment, we observed a person bending down under a table during lunch stating, ‘why is there glass on the floor?’ whilst proceeding to pick a small piece up. Care staff did not take action to ensure the environment was safe for the person and others living at the service. We also found items within the home that were accessible to people which could cause potential harm. Staff had not recognised this and failed to keep such items in a secure area.

The registered manager and provider failed to have sufficient systems to ensure the environment was safe. For example, a fire risk assessment completed in September 2023 identified several actions and deficiencies in relation to fire safety. This included faults on the fire panel and fire doors which did not close properly. Action had not been taken to remedy the issues found or mitigate the known risks to people. We asked the Registered Manager how they would evacuate people safely from the first-floor near to the set of stairs with the broken stair lift. The registered manager told us they would close people’s doors and await the arrival of the fire service. This placed people at significant risk of harm in the event of a fire as people’s fire doors did not close as required to keep people safe.

Staffing levels and deployment meant that people did not consistently receive safe, good quality care that met their needs. During daytime hours, there were four care staff on shift, reducing to three in the afternoon. These staffing numbers were insufficient to meet people’s needs and keep them safe. During the night, only two members of staff were on shift to provide support to people. This placed people at risk of harm in the event of an incident or emergency where people required the support from two staff. A person told us, “You can sit hours when you want to go to the toilet, they [staff] don’t care, I haven’t had an accident waiting luckily. They [staff] never have time to chat. There is a bell but they turn it off so I have to shout if I need something.” A relative told us, “‘I don't think there are enough staff. For example, there are many times when I visit between 7:00pm and 9:00pm at night and as some of the residents need two carers to put them to bed, there are others who are left alone for some time without help.” Following the first site visit and feedback from the inspectors, the provider increased staffing levels for both day time shifts and night shifts.

Not all staff felt there was enough staff on shift to meet people’s needs and keep them safe. A staff member told us, “Sometimes you feel guilty, useless, can't do enough, we would be really stuck if there was another emergency to deal with. We have additional jobs to do cleaning, laundry during the night too." Another staff member said, “Theres not enough staff. In the mornings, the bells are going off and there are not enough people [staff] here. The ratio might be fine but the residents needs change every day.”

People were left unattended in the communal areas whilst staff supported other people in their bedrooms. This meant staff were not available to support people with their individual needs. One person was tearful and distressed and there were no staff available to provide any support or reassurance for a period of two hours. Another person was seen in their bedroom without the support from staff with their breakfast and drink for over two hours. Staff attended to this person when prompted by the inspector.

The registered manager used a dependency tool to calculate staffing levels. However, we were not assured this considered people’s safety, individual needs, and the layout of the building. Staff training records showed not all staff had received the training required to carry out their role effectively. Staff were recruited safely with appropriate checks in place such as references from previous employers and Disclosure and Barring Service (DBS) checks.

Most people and relatives we spoke with did not report concerns with the cleanliness of the home. However, people were not protected as much as possible from the risk of infection because the premises and equipment were not always clean and hygienic.

The provider had not ensured there was enough staff to maintain the cleanliness of the home and prevent the spread of infections. The service had one dedicated member of staff during the day to complete cleaning tasks throughout the whole home. This member of staff also supported the carers by providing support to people during the day with their meals. Most staff told us they felt the home was clean, however, one staff member said, “Not all areas are clean. The workload is too much for just a single individual to do." Another staff member said, “I do not feel the home is clean enough or to a high enough standard at times, but I do feel it is too much for just one cleaner within the home." Following the assessment, staffing levels were increased to ensure there was enough staff to clean the home to a higher standard.

During our assessment, we found concerns with the cleanliness of the environment, equipment and furniture that increased the risk of harm to people. The home was visibly unclean with areas of concern such as black mould in bathrooms, threadbare and stained carpets, damaged and stained armchairs and dirty moving and handling equipment. This meant people were not protected as much as possible from the risk of infection because the premises and equipment were not kept clean and hygienic. During our second site visit, we observed some improvements had been made however, further improvements were required, and changes needed to be embedded into practice to ensure people were protected from the risk of infection.

Systems to assess and manage the risk of infection were ineffective in identifying and addressing the concerns found during the assessment. Roles and responsibilities around infection prevention and control were not clear. The registered manager last completed an audit of infection prevention and control in January 2024. This did not include any checks on people’s furniture or moving and handling equipment. There were no records to show communal areas, furniture and equipment had been checked and cleaned regularly. Policies had not been reviewed to ensure they remained relevant and up to date. Following the assessment, the Local Authority Infection Prevention and Control Team conducted an audit at the service and found 17 areas for improvement.

People did not always have access to their prescribed medicines when needed. People were unable to be given PRN ‘as required’ medication during the night as there were no trained members of staff on shift to do this. This meant people were at risk of experiencing pain or discomfort as they were unable to receive pain relief. During the day, people’s medicines were administered, as prescribed, by trained staff. The registered manager was in the process of training additional staff to ensure people had access to their medicines at all times. People’s records detailed their preferences as to how they would like to take their medication, for example, with water.

Staff administering people’s medicines were confident and knowledgeable about safe medicine practices and procedures. We observed staff administering people’s medicines safely, including explaining to each person what the medicine they were having was for.

There was a system in place for the ordering and storage of people’s medicines. However, we were not assured medicines were always stored securely to ensure people who had not been prescribed the medicine, did not have access to them. For example, on the first day of the assessment, we found prescribed creams that had not been stored appropriately and were accessible to people. Records showed people’s medicines were administered as prescribed. Medicines to support people with any distress or anxieties were administered appropriately. There were systems in place to monitor the temperature of medicines storage areas. There were appropriate arrangements in place for the safe storage and management of controlled drugs.