Oak Cottage

People told inspectors they felt safe living at the home and with the staff team.

“People told us they felt safe living in the home and with the staff team that supported them.” from the report

The home was satisfactorily clean, and people were supported to keep their own apartments clean and tidy.

“The home's environment was satisfactorily clean and people were prompted and supported to keep their own apartments clean and tidy.” from the report

People were supported to take part in activities they enjoyed, use the community and maintain family relationships.

“People were supported to maintain positive family relationships and family members visited without restriction. This was good practice.” from the report

Records did not reliably show which medicines had been given, and stock could not be checked properly. Some staff could not give required medicines at night, and there was not enough evidence that staff were competent to give injectable medicines.

“There was no robust system in place to account for medicines.” from the report

People's health, safety and emotional needs were not adequately assessed or supported. This included risks linked to domestic appliances, changes in accommodation and emotional distress.

“Risks to people's health, safety and welfare were not adequately assessed, and mitigated against to prevent avoidable harm.” from the report

Mental capacity assessments and best-interest decisions were not always completed. Conditions attached to some Deprivation of Liberty Safeguards authorisations were not followed.

“People's legal right to consent to and make decisions about their care and treatment had not been supported in line with the MCA.” from the report

Audits had not found the problems with medicines, care planning or Legionella monitoring. Provider and managerial oversight was not strong enough to protect people from avoidable harm.

“The governance arrangements were not robust. Managerial and provider oversight was poor and service delivery did not always promote good outcomes for people.” from the report

Agency and bank staff were regularly used to fill rota gaps. Not all agency staff had profiles showing their suitability, training, skills and competence.

“Not all of the agency staff had staff profiles in place for the manager and provider to be assured of their suitability.” from the report