Charnwood Oaks Nursing Home

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 requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to the oversight and governancein respect of the condition of premises and equipment, dehydrationand ensuring contemporaneous records were kept.

This service scored 32 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

The service did not have a consistently shared culture that ensured safe, compassionate standards across all units and shifts. Some staff described values-focused working, including different cultures coming together in residents’ interests, but these values were not consistently reflected in day-to-day practice. The repeated failures in dignity, responsiveness, infection control and risk management showed the service culture did not consistently protect people from avoidable harm or assure quality.

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 have the skills, knowledge, experience and credibility to lead effectively.

Leadership did not provide effective clinical oversight or demonstrate sufficient knowledge of risks and people’s needs. The service did not have robust processes in place at the time of the inspection to enable the the leadership team to provide accurate information to inspectors on people's health conditions and needs in an expeditious manner. These failings reduced assurance that leaders understood the service’s clinical risks and could identify and respond to deterioration in peoples’ health in a timely way. Following the inspection, the service implemented a clinical risk register.

Staff feedback about leaders was mixed. Some found leaders worked well together with a staff member stating, “Deputy is amazing under new manager - whole morale of the home changed for positive under this manager.” However, there was a substantial amount of negative feedback given by staff, including comments such as “[The registered manager] doesn’t listen.” and “The manager has people they get on well with but not approachable to other staff and not a people person.”

People did not always feel they could speak up and that their voice would be heard.

Staff described some teamwork and support, particularly from nurses, and staff meetings were held. However, staff also described barriers to raising concerns and seeing change occur. Staff described limited routes to provide feedback and felt leaders were not always receptive to suggestions. One staff member explained, “[The manager] argues back when I make suggestions so I don’t feel comfortable raising ideas.”

The protection of whistleblowers was also raised as a concern by staff. One staff member stated, “Whistleblowing is not managed well. Whistleblowers are not protected. There was an example of a staff member whose identify was given to the person being whistle blown about.”

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff described both strengths and concerns. Staff recognised diversity and described coming together in residents’ interests, but staff also described inconsistent communication and involvement across staff groups and shifts. One staff member, speaking about a recent visit from stakeholders, said, “[The registered manager] didn't tell us any outcomes directly so it wasn't helpful, we needed to know how we were performing or how to improve. We do work hard and we should be made aware of issues when they come up.” These factors reduced assurance that all staff experienced inclusive communication and equitable involvement in service improvement. Following the inspection, the Nominated Individual clarified the information dissemination process, and told us key personnel attended a regular meeting each day to gather essential information, and they were then responsible for disseminating this to their teams. The Nominated Individual advised this was the best way to share information within such a large team.

Staff also described exclusion when colleagues spoke languages not understood by all, and said communication about outbreaks and inspection outcomes was not timely. These issues meant the culture did not consistently support open communication and effective improvement.

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.

The provider’s governance systems were not effective and did not identify or address the concerns found during this inspection. Audits were not robustly completed and did not identify issues inspectors found, including concerns about infection control, hydration monitoring, oral care, pressure care, staffing risks and risk management plans.

Where repeated themes were discussed at staff and resident meetings, actions were not always effective or sustained. In addition, staff described a breakdown in communication between care staff and registered management, with concerns raised by care staff not consistently reaching the registered manager in a way that led to robust action. One staff member stated, “Managers need to pay more attention.”

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

The service worked with external professionals and families described regular professional visits. However, weaknesses in medicines systems, clinical monitoring and internal communication reduced assurance that the service consistently worked in partnership in a way that prevented avoidable risk and ensured timely escalation.

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 and research.

The provider did not demonstrate effective learning from previous errors. We were concerned that this was the third inspection where significant safety concerns were found and that at the last two inspections the service had been in breach of Regulation 12 Safe care and treatment. This inspection again identified serious concerns, which demonstrated the provider had not taken robust action that was sustained to drive improvement. This meant learning and improvement systems were not effective and did not protect people from repeat failures.