Oakwood Acquired Brain Injury Rehabilitation Service

We found two breaches of legal regulation relating to the safe management of medicines and systems for oversight to ensure the service was well run.

People’s experience of feeling safe varied according to the staff on duty and families had concerns in relation to the use of agency staff. Risks were not always effectively managed and it was not clear that lessons were learnt when shortfalls had been noted. We identified a breach of regulation in regard of how people were supported to take their medicines as we could not be certain all staff had appropriate training and checks of competency to ensure they were able to administer medicines safely, or that accurate records were being maintained. Not all staff had completed the required training, and work was ongoing to improve training compliance. Improvements were needed to the premises to ensure the safety and comfort of the environment for the people living at Oakwood.

People’s needs were assessed and people were supported to access a range of therapies including physiotherapy and speech and language therapy where needed. However, healthy diets were not always promoted, and there was limited evidence that therapeutic interventions were being consistently delivered by the care team following recommendation by the therapy team. People told us instances of poor organisation meant some external appointments had been missed. Where people lacked capacity, appropriate assessments and authorisations were sought. People were asked for consent before care was delivered.

We observed kind and caring interactions between staff and people and people felt well cared for by permanent members of the staff team. People’s independence was being supported with the input of the therapy team. Staff felt supported and were generally happy in their roles.

People were supported to plan for the future and move onto independent living. Staff supported people to access the services needed and processes for ensuring continuity of care were in place through the use of a hospital passport system. People’s care records were not always personalised, and action was in the process of being taken by the provider to address this matter.

An interim manager was in post but there had not been a manager registered with CQC for some time. There was inconsistent evidence of oversight with gaps in how some processes were completed. Many of these processes had been reintroduced since the interim manager and deputy manager had come into post. The provider had an action plan but limited progress had been made. Further work was needed to ensure action that was deemed completed had embedded. The interim manager was responsive to feedback and took immediate action where this was needed.