Oakhurst Lodge

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• 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

There were systems, processes, and practices in place to ensure people were protected from abuse and avoidable harm. Staff undertook safeguarding training and safeguarding policies and procedures were available. Staff had a good understanding of safeguarding and were confident to raise concerns if needed, they told us, they were encouraged by the management team to raise concerns. Incidents were investigated and lessons learned if care had not gone to plan. Risks associated with people’s health conditions and support needs, were assessed, monitored, and mitigated effectively. People received their medicines as prescribed. There were safe recruitment processes in place. There was enough suitably skilled staff available to meet people's needs. Infection prevention and control was safely managed, and people lived in a clean home.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We were unable to gain the views of people during this inspection, however, we did speak to their relatives. Most of the relatives we spoke to, told us about the improvements the home had made following our inspection last year. 1 relative told us, “There’s a lot of evidence of improvement. They’ve changed some staff and improved the process of communication with better documentation. We get more information and are told when incidents occur.”

We reviewed information and we spoke with staff members and the registered manager about learning culture. Staff were confident they could report concerns to their managers, and this would be acted on. Staff told us there was a culture of safety and a no blame approach used by the leadership team. A staff member told us, “When there is a safeguarding concern, there is learning. There is a lesson learnt document to read and sign, and it is discussed in handover to ensure staff have read it and understood it.” We asked the registered manager how they learn from complaints, the registered manager was able to describe to us a complaint they had recently managed, they were able to confidently describe the procedures they followed, the timescales involved, the learning taken, how the learning was shared with staff and how the outcome was shared with the complainant. The registered manager was able to confidently describe what duty of candour means and gave examples of when they had followed this in practice. Evidence to corroborate this was seen.

Incident forms showed staff had reported incidents appropriately to the registered manager and they had reviewed these to ensure appropriate action had been taken. Notifications of incidents were also sent to the psychiatrist who worked on-site at the home as part of a multi-disciplinary team (MDT). The psychiatrist completed a quarterly incident review, they assessed themes and trends and triggers which was sent to the registered manager to consider in ongoing support planning. Lessons learnt were discussed in MDT meetings and were included in safeguarding files. We reviewed a lesson learnt following a relative raising a concern which included a review of the actions taken. We reviewed peoples debrief forms which were in regular use. There were 2 types of debrief forms used for people, 1 contained simple words, the other contained pictures so a choice of form could be used depending on which suited a person best. We reviewed staff debriefing forms which were also completed consistently and were signed off by a senior staff member. We reviewed 3 team meeting minutes which contained evidence of lessons learned being shared with the staff team. We were assured, incidents were reported, recorded, and were reviewed to find common trends and themes. The registered manager had oversight of incidents. Debriefs for staff and people were taking place. Lessons learned were shared with the whole team and the principles of duty of candour were being met. We were assured a learning culture was embedded throughout the home.

We were unable to gain feedback from people relating to a person transitioning into the home.

We spoke with staff members and the registered manager about safe systems and pathways. 1 staff member told us, “People are fully assessed before they come to the service and information is given to care staff about their care needs.” Another staff member told us, “For the admission of 1 person, staff went to the person’s former home and learnt from the way the support workers at the former home supported the person, including the ways the person likes to be communicated with. The person visited Oakhurst Lodge prior to moving in. The manager was involved in the transition it was a very serious process to help the person to adjust to the new environment. They have adjusted very well.” This evidenced the appropriate information was shared with the staff team who would be supporting the person in their new home. We spoke to the registered manager about their approach to safety when supporting a person through a transition journey. They were able to give us a comprehensive response which assured us the appropriate processes were in place, which included taking a multi-disciplinary approach. The registered manager was able to confidently explain what processes were in place to monitor new admissions into the home, they told us, “We have daily notes, risk assessments, incident reporting and analysis, monitoring patterns and asking the person how they are doing, asking the people who know the person best how they feel it is going, having a planned schedule for review, e.g. 6 weeks, 3 months, 6 months and 1 year.” This provided evidence people were assessed and deemed to be a suitable fit before moving into the home. We were assured by the multi-disciplinary approach which was taken. We were confident ongoing monitoring of people who had newly moved into the home was also taking place.

We sought feedback from professionals to ask if the provider worked in collaboration with them. One professional told us, “I will work closely with the Oakhurst team to ensure the transition is as person-centred as possible. The Oakhurst team will work closely with all parties connected to the person, gathering as much information as possible and striving to ensure continuity of support and care.”

We reviewed a pre-admission assessment document for a person who was admitted to the home. We found a comprehensive assessment was completed, which detailed the level of support the person needed. Risk assessments and care plans were reviewed as part of the assessment process. Health needs were shared including in relation to specific health conditions, for example, epilepsy, which highlighted the need for staff to be trained in epilepsy and the administration of rescue medicines. When we reviewed staff training, it evidenced staff were trained in epilepsy and the administration of rescue medicines. An MDT approach to the assessment was taken. Therefore, we were assured risk assessments were in place, needs and training analysis were reviewed, the relevant training was provided, and staff were given the appropriate information. The provider effectively collaborated with other providers and external stakeholders which meant, there were safe systems and pathways for people who were moving between services.

Most relatives told us they felt their relatives were safe, and they gauged this by their relative appearing happy and being happy to return to the home after spending time with their relative. A relative told us, “With the new team working together well and weekly reports from our relative’s key worker, we can see what our relative is doing, it’s working now. We don’t have to chase and ask what our relative needs. Our relative is doing more now and is involved in the garden project. They have more choices of what to do.” When asked if staff manage risks, a relative told us, “They certainly know how to calm my relative quickly in a calm way so they must know them.” Following the improvements which have been made since the last inspection, most relatives told us, communication had improved, staff knew their relatives well, and their relatives received the appropriate support.

Staff members were confident leaders would take safeguarding concerns seriously. 1 staff member told us, “The managers remind staff all of the time, they send emails to remind staff to report, telling them what they need to do, they offer support around this.” The registered manager had a good understanding of safeguarding and was able to tell us what was in place to ensure safeguarding concerns were raised and how risks were mitigated when concerns arose. They were able to give examples of learning which had happened following safeguarding concerns and how this was shared with the wider staff team. When asked how people were supported to raise concerns, the registered manager told us, “We have an independent advocate who visits once a week, who will talk to people in their preferred way of communicating, they will observe what is happening. We also have easy read safeguarding board. We ask if people want to change anything or talk about anything. We have debriefs for people after incidents. These are in 2 formats due to people’s differing ways of communicating.” The registered manager was able to tell us, how they ensure people and staff are protected from bullying, harassment, avoidable harm which breaches their human rights. They demonstrated they had a good understanding of deprivation of liberty safeguards (DoLS), of their responsibilities and the conditions different people had on their DoLS. We were assured the registered manager had robust procedures in place to ensure safeguarding concerns were raised and managed appropriately. Procedures were in place to protect people from bullying, harassment, and avoidable harm and DoLS were in place and managed effectively.

We observed people looked cared for and were well dressed. We observed the lunchtime experience for people. We saw 1 person declining what was on offer for lunch, and staff taking the plate away and coming back with an alternative option for them. We did observe staff positively engaging with people however, we also saw a couple of areas of where staff missed an opportunity to engage on a more meaningful level. Where one concern was noted, the registered manager dealt with this appropriately and put plans in place to mitigate the risk of this happening again. The registered manager was aware of where things could be improved and was working towards this.

We reviewed the providers safeguarding adults’ policy which had recently been re-issued and contained relevant and up to date information. We reviewed the provider’s training matrix and noted most of the training had been completed. Where training was outstanding, the registered manager was aware of this and had plans to ensure the training would be completed in a timely manner. A DoLS tracker was in place, and we saw evidence this was regularly updated. We reviewed the safeguarding folder. Safeguarding notifications were made to CQC, and safeguarding referrals were made when required. Safeguarding protection plans contained identified risks and detailed outcomes with an agreed action plan in place. Including, other options to minimise harm, detailing any changes to service provision, monitoring and reviewing arrangements and incorporating adjustments into care plans. Debriefs for people and staff were seen to be in place following incidents. The registered manager had a good oversight of safeguarding concerns within the home and the staff team had been provided with safeguarding information and training to aid their understanding. Evidence reviewed showed staff were raising safeguarding concerns when they arose, and the appropriate authorities and relatives were being notified of these. We were assured staff received the appropriate training to aid them in fulfilling their role and maintain people’s safety. Therefore, we were assured the appropriate safeguarding processes were in place.

We spoke to relatives about this, relatives were able to give us specific examples of when their relative had been involved in managing risks. 1 relative told us, “If there is an indication my relative is becoming increasingly agitated, staff step in and support my relative to calm quickly before the situation escalates.” We were assured people were supported sensitively to manage their distress and emotions by staff who knew them well.

We spoke to staff members and the registered manager. Staff members confirmed people have risk assessments and care plans were in place to mitigate the risks to people. When we asked about how risk was mitigated, 1 staff member gave us an example of a person wearing ear defenders when in noisy environments, as noise can increase their anxiety levels. Another staff member told us about the staffing ratio for a person when they are out and about, to ensure their safety and the safety of others. All staff we spoke to, were able to confidently tell us how they respond in a positive way to people’s distress or agitation. 1 staff member told us, “I have been given the right level of support and training. The first thing to do is try to de-escalate the situation with the least restrictive method, reassurance and redirecting the person. Remove the trigger such as noise and redirect to a quiet place. We always analyse the situation and assess.” The registered manager was able to give us good examples of how people were involved in decisions about risk. The registered manager told us, the provider employs an in-house MDT of professionals who work in the home to support the person and registered manager in relation to risk taking. They also told us about external professional’s they work in conjunction with. When asked, how do you ensure staff are aware of risks and risk management plans, the registered manager told us, “We make sure staff have a copy available. We have a read and sign folder which staff read and sign. We also add it to the handover if a new document needs to be read and signed. We also discuss this at team meetings."

We observed staff members supporting people through periods of distress. We observed staff were supportive and kind and offered redirection, this led to the distress de-escalating quickly. We observed staff members following the guidance in people’s positive behavioural support (PBS) plans.

We reviewed 3 people’s files. We noted the information within people’s care plans were detailed and provided a clear picture of who the person was and how they liked to be supported. We reviewed information relating to epilepsy management and emotional support plans. We found these plans to be detailed and they contained enough information to ensure when followed, the person would be supported safely. We reviewed risk assessments which were detailed and included people being supported to take positive risks. These were not reviewed in line with the providers policy, however, the registered manager assured us they would review these in line with their policy going forward. We reviewed the staff training matrix and noted most of the training had been completed. Where training was outstanding, the registered manager was aware of this and had plans to ensure the training would be completed in a timely manner. People had risk assessments and care plans in place which helped staff to mitigate the risks to them. Staff were able to confidently tell us how they respond in a positive way to people’s distress or agitation. Examples provided by staff showed evidence positive risks were being taken. Other professionals were involved in supporting the team to manage risks and documentation relating to risks was shared with the staff team. We were assured the provider was involving people to manage risks.

We spoke with relatives, when asked if the home was safe and if their relative could move around freely, 1 relative told us, “It’s a safe building, well laid out and suits the people. They can move around without impacting on each other. There’s easy access to outside, has a nice garden, and my relative can get to their own room which overlooks the garden. My relative has their own bath and shower which is really helpful. We have no concerns with the environment.” Another relative told us, “The home is always clean and tidy. Whenever we go to visit our relative, the home always looks nice.”

A staff member spoken to was able to explain the procedure for fire drills. They detailed the exit to evacuate through, they told us people being supported needed encouragement to evacuate and a roll check was completed when everyone was at the fire assembly point. Staff told us, they did not have any concerns in relation to environmental safety within the home. The registered manager was able to describe the process of fire drills and shared with us an example of learning taken from a recent fire drill. We asked the registered manager, who oversaw the checks of the building, they told us, “We have a maintenance person who does all the checks. I also do a daily walkaround to keep an eye on everything. I will then report any concerns I have to the maintenance person. Night staff also complete checks at night to ensure the building is secure.”

The home was clean and well maintained. We observed window restrictors were in place. The stairs within the home were safe and had handrails in place for people to use if needed. The fire exits were free from obstruction. We noted the fire doors were well maintained with no gaps and the fire extinguishers were being regularly tested by the appropriate contractors to ensure they remained in working condition.

The provider has a designated maintenance person working in the home who completes the required works and maintenance checks. We reviewed monthly health and safety audits which were detailed and consistently completed. We noted actions were followed through to the next audit. We reviewed the maintenance file and noted in date certificates in place for electrical testing, portable appliance testing (PAT), gas safety, asbestos and legionella. We noted checks in place for equipment including, fire, personal protective equipment (PPE), carbon dioxide, water, window restrictors and ladders. We reviewed fire drill records and noted these were taking place regularly to ensure staff could evacuate people safely in an emergency. We reviewed the provider's contingency plan which included a list of important emergency contact numbers and a list of local hotels, church halls and community halls to decant to if needed. We were assured people lived in a clean, well-maintained environment which they were able to move around freely. We were assured the appropriate maintenance checks were in place and the registered manager had good oversight of this. Staff and the registered manager understood their roles and responsibilities to ensure the environment was safe for the people they were supporting.

We spoke with relatives about staffing. 1 relative told us, “There always seems to be enough staff and our relative has their 1-1 support hours. When we take our relative back to the home, staff come out to meet them. We’ve noticed our relative is happy to interact with the staff. The staff always smile and seem to have a good rapport with our relative and they are happy to walk inside.” When asked if there were things, they would like their relative to do but, are unable to because of lack of staff, 1 relative told us, “It appears the home still have trouble recruiting staff who drive. Again, some progress is being made in this area with a new driver who has just started.”

All staff members spoken to, told us there were enough staff to support people. When asked if anything is difficult to achieve with current staff levels, 1 staff member told us, “The staff numbers have improved since the new management team have been brought in, which is the reason why the people do a lot more activities now.” When asked if they can support people to maximise their independence, 1 staff member told us, “We always give people the time to do things for themselves, we are there to support and guide them.” When asked about their induction, we received positive responses from all staff members we spoke to. 1 staff member told us, “It was very thorough and there was enough access to support. I had all the support required and I was shadowing for two weeks before I started taking the lead to support the people.” When asked about the training programme, 1 staff member told us, “The training programme is good. If staff want more training or profession qualifications, there are more courses available.” All staff members spoken to, told us their supervision sessions were meaningful. The registered manager explained how they ensured there are always suitably trained staff on every shift. The registered manager described a comprehensive induction process for new staff which included mandatory training which all staff members were required to keep up to date with. The registered manager told us about service specific training for staff. They also told us, how they ensure staff were following best practise guidance. We asked the registered manager about the recruitment process, they were able to give us a step-by-step detailed response of the process which was in line with schedule 3 of the Health and Social Care Act 2008.

People who had 1 to 1 support were being supported in line with their contracted support hours. We observed people were supported by staff members who knew them well.

We reviewed recruitment files for 3 staff members which included staff who had been employed from overseas. All relevant checks were in place including right to work in the UK. We reviewed references and noted references were sought for all previous care jobs. Gaps in employment were accounted for. Disclosure and barring service (DBS) was in place. We reviewed agency profiles for agency workers currently working in the home. This included DBS information and all training details which gave the registered manager oversight and assurances these were in date. We did not see any agency induction forms for the newest agency staff working in the home. We asked the registered manager about this. They were unable to locate them and told us, they will ensure moving forward these were completed. We reviewed supervision records and were assured these were taking place in line with the provider’s policy. We reviewed induction records for newly employed staff. Induction records evidenced all relevant information a staff member needed to be inducted into the home. We also reviewed probation records. We reviewed the provider’s staff training matrix and noted most of the training had been completed. Where training was outstanding, the registered manager was aware of this and had plans to ensure the training would be completed in a timely manner. We reviewed rotas for a 1-month period. The rotas were clear and in line with people’s support hours. All shifts were covered and if there was staff sickness the shift was covered with overtime or agency staff. We were assured staffing levels were appropriate and the provider had robust recruitment processes in place. Staff received a comprehensive induction, meaningful supervisions and were trained to be able to safely carry out their role. We were assured people’s needs were assessed and the rota reflected this and where there was a concern, for example, a lack of drivers, the provider had taken action to address this.

Relatives told us they had no concerns with the environment or cleanliness of the home.

All staff we spoke to, confirmed the home was clean. 1 staff member told us, “There is a new cleaner, they are extremely good. Staff members assist with cleaning by just tidying things as and when they see that it needs doing to aid the cleaner.” Another staff member told us, “The people have a very good clean home, staff will do some tasks and cleaning and try to encourage people to get involved to support their independence.” All staff confirmed they used personal protective equipment (PPE), had access to control of substances hazardous to health (COSHH) cupboard which was kept locked and had attended infection prevention and control (IPC) training. The registered manager was able to describe how they assured themselves staff were following IPC procedures and understood their responsibilities in relation to IPC. They were able to tell us what training staff attended and how they ensured COSHH products were stored securely. The registered manager described to us the procedure for managing infectious diseases.

The environment was visibly clean and there were no malodours. We inspected the kitchen which had a food hygiene rating of 5. The kitchen was clean. In the fridge there were dates on all open foods and jars. There was a good selection of fresh vegetables, fruit, and food available. There was a sign to say make sure the kettle is left empty, we checked the kettle, and it was empty. This reduced the risk of scalding to people. 1 kitchen drawer was locked, it contained sharp knives. This meant the risk of harm of people hurting themselves was reduced.

We reviewed cleaning schedules. We noted these were consistently completed and included evidence of deeper cleaning. 1 cleaning rota also contained evidence of a concern raised to the registered manager which was shared with the team for future learning. We reviewed IPC, hand hygiene and mattress audits and had no concerns. We reviewed the provider's IPC policy which was issued in May 2024 and was in line with current legislation. The environment was clean and appropriately maintained. We were assured staff understood their responsibilities in relation to IPC and the provider had the appropriate oversight and systems in place to ensure IPC was managed safely within the home.

We were unable to gain people’s experiences relating to medicines.

All staff we spoke to, who had the relevant training and had been assessed as competent to administer medicines, were able to describe in detail how they administered medicines. When we asked staff about records, they were able to tell us about sheets for recording medicines administration and body maps to show where topical creams should be administered. All staff spoken to, told us they would report a medicines error to a member of the management team. They would also contact a GP or 111 and would record the error on an incident form. Staff were able to confidently tell us how to administer as required (PRN) medicines. 1 staff member told us, “I would give paracetamol if a person was behaving in certain ways which we identify as them being in pain as per their care plan.” The registered manager was able to tell us how they ensured medicines were managed safely. They told us about the medicines training staff were required to attend which included eLearning and competency assessments. The registered manager told us they maintained oversight of the use of sedatives / antipsychotic medicines. They said, “I have a monthly review with the psychiatrist where we discuss all medicines and confirm if people are still on these specific medicines. We discuss plans to reduce psychotropic medicines at these reviews.”

People’s medicines were, stored, administered, and disposed of safely. People prescribed medicines to manage anxieties had ‘when required’ protocols and positive behaviour support plans (PBSP). These described the triggers, good, OK and distressed behaviour, non-medical interventions, and the threshold for administering medicines. Most protocols for ‘as required' medicines contained sufficient detail to guide staff when and how to administer these medicines safely. We spoke to the registered manager about 1 protocol which described a variable dose and lacked detail on when to prescribe which dose. The registered manager assured us, they would rectify this. Anti-epileptic rescue medicines were prescribed for some people. Each person had an individual bag for these medicines for when they went out. These bags contained their medicine, when required protocol, epileptic seizure record form and a stop watch to ensure seizures could be timed, and the appropriate medical support requested as directed in the protocol. Some people were prescribed paraffin based topical creams that can under certain circumstances act as a fire accelerant. There was a risk assessment in place to manage this risk. We were assured medicines were administered safely and managers and staff understood their responsibilities in relation to medicines management.