Red Oaks Care Community

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulations in relation to good governance.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

While the statement of purpose included commitments to privacy, dignity and safety, these were not consistently upheld in practice. For example, we observed a bedroom door with a hole that compromised privacy and dignity, and personal information left in communal areas accessible to visitors. The provider stated they would maintain the building and grounds in a safe condition. However, we found many instances at this inspection where people’s physical safety had been compromised as a result of poor maintenance of the physical environment. These findings indicate that although the provider articulated key values, these were not consistently experienced by people living at the service.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not apply their skills, knowledge and experience to lead effectively.

Leadership was inconsistent and did not always support the delivery of high-quality, person-centred care. While some staff described the deputy manager as approachable and supportive, others reported limited visibility of senior leaders. This lack of consistent leadership presence meant that staff did not always have the guidance or oversight needed to maintain safe standards of care.

Leaders were not applying their skills to ensure people lived in a safe and clean environment and had not identified several significant concerns we found during this inspection. This failure to recognise and address risks meant people were living at an increased risk of harm from unsafe conditions, this posing an ongoing risk to their health and wellbeing. Although leaders expressed commitment to improvement and had begun implementing responsive actions, these were not yet embedded or consistently monitored. There was no registered manager in post at the time of inspection however a manager was in role and was intending to become the registered manager.

The provider fostered a positive culture where people felt they could speak up however a lack of clear, accessible information meant staff were not fully empowered to speak up.

The service fostered a generally open culture where staff felt able to raise concerns. Staff told us they felt supported by the deputy manager and could approach the deputy manager and regional manager with issues and felt listened to. However, there were gaps in the availability of clear information on how to report safeguarding concerns externally. Staff reported they would need to search online for contact details, and safeguarding and whistleblowing policies displayed in communal areas were incomplete. Despite this, staff felt confident that management would respond appropriately if they raised concerns internally, and there was no evidence of a closed culture. This lack of clear, accessible information meant staff were not fully empowered to speak up, despite feeling generally supported by the management team.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff consistently told us they felt they were treated fairly and supported regardless of their backgrounds. Policies addressing anti-discrimination were in place, and staff were aware of them. There was no evidence of discriminatory practices, and staff reported feeling respected and valued. Reasonable adjustments were considered where needed, and staff described a positive and inclusive working environment.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance systems were ineffective and did not ensure safe, high-quality care. Audits and spot checks failed to identify significant risks, including unsafe environmental conditions, poor infection prevention and control, and unsafe equipment. For example, an unsecured cable along the edge of the room, uncovered radiators, and broken pedal bins were not identified prior to assessment. There was a lack of infection prevention and control oversight, audits had not detected heavily soiled pressure cushions or cleaning schedules that were often not completed. This put people at an increased risk of harm from communicable illnesses.

Medication oversight was weak, with expired medicines competencies and incomplete PRN protocols at the time of assessment. These failings placed people at risk of harm and demonstrated a lack of robust governance and accountability.

Audits were ineffective at identifying risks or concerns in relation to people’s equipment. For example, the monthly wheelchair audit had failed to identify concerns that we found at this assessment. This places people at an increased risk of harm and injury.

There was a lack of effective oversight of peoples care records for example, some care plans contained contradictory or unclear information. Failing to have effective governance in place to ensure people received support in line with their needs placed people at an increased risk of prolonged harm. Whilst the service was open to supporting people with a learning disability, they had not always considered guidance such as right support, right care, right culture.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

The service worked with external professionals to support people’s health needs. We saw evidence of GP visits, referrals to dieticians, and engagement with speech and language therapy where required. Staff and relatives confirmed that communication with healthcare partners was generally timely and effective. The service also encouraged family involvement in activities and events, such as a recent Christmas party, which was well attended and positively received.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice.

Although the provider had systems for identifying and communicating lessons learned, these were not always consistently embedded in practice, and some previously identified issues persisted.While leaders acknowledged the need for improvement and had begun developing action plans, these were not yet embedded or consistently monitored. Audits were ineffective, and lessons from incidents were not always translated into practice. For example, repeated issues with infection prevention and control and environmental safety persisted despite previous checks. Where external partners had identified concerns, these had been actioned. However, many issues identified had not been highlighted through their own internal processes.