Archived: Oak Tree Mews

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 care home leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first assessment for this care home under its newly registered provider. This key question has been rated 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 care home was in breach of legal regulation in relation to governance, notification of incidents, and failure to submit changes to the statement of purpose.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders had a positive approach to their plans and direction for the future of the care home, however, the care home needed to improve their monitoring and governance systems to enable them to achieve their goals. Processes were not always robust and therefore were not always suitable to ensure progress could be monitored and reviewed against delivery of the strategy. Many processes to support positive changes were in initial planning stages rather than in process, such as arranging additional dementia training for staff, conducting staff supervisions, and changing accounts and paperwork over from the details of the previous registered manager to those of the current registered manager. At the time of inspection, the current registered manager had been in post for 5 months.

We found delays and a lack of oversight to ensure safety in some changes which had been made. For example, the registered manager had implemented a change in the process for administering medicines in June 2025 which involved switching from an online system back to a paper-based system for medication administration records (known as ‘MARs’). The paper MARs which were used in this time showed significant discrepancies, gaps in recording, illegible entries, and errors, and there was no evidence of safe leadership oversight of this process. This meant people were at risk of being exposed to errors in their medicines administration. After June 2025, the team reverted to the use of the online system after establishing it was safer. A senior staff member told us they had always thought the online system was safer. Medication audits had not been completed during the months of July and August 2025. The lack of safe oversight of this trial period demonstrated a lack of shared understanding and direction which put people at risk.

During our inspection, we found the care home was displaying a report in the home which was assessed and rated under the previous provider. This gave people a false representation of the care home’s rating. There were multiple other instances of the previous provider’s name and paperwork being used in the care home which could be misleading to staff, people and visitors.

Leaders were positive about making improvements in the care home but did not always have the skills, knowledge, experience and credibility to lead effectively. Leaders were not always delivering the organisational vision effectively and were not always ensuring risks were professionally managed.

During our inspection, leaders were not always able to offer assurances relating to the concerns we raised. There was evidence the registered manager did not always take appropriate action in instances where risks were identified. For example, a medication audit from 2 months before the inspection, completed by the registered manager stated the action “homely remedies need updating”, however, at time of inspection no action had been taken to review the homely remedies and mitigate the significant risks we identified. There were gaps in the completion of vital audits (such as the kitchen and medicines audits) which meant people were exposed to avoidable risk associated with poor practice in these areas. The risk of a staff member working directly with people without having had a DBS check had not been mitigated with any risk assessment or actions, which meant people were not adequately safeguarded.

We found instances where leaders had not informed CQC of notifiable events which suggested they did not always fully understand their regulatory responsibilities. The provider had also failed to notify CQC of changes to the care home’s statement of purpose in line with their registration requirements.

Despite the lack of formal process to encourage staff to raise concerns, the provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff members understood the meaning of ‘freedom to speak up’ and said, “Ideas are freely expressed by everyone and there is no form of discrimination or prejudice. The service is inclusive, and every staff is treated fairly”. Another staff member said “In our care home we have an open-door policy, and we can come or reach to our manager or senior leaders anytime to raise any issues. We don’t feel afraid to speak up in our home and we discuss everything together for the betterment of the home”.

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. The provider employed multiple staff members from overseas via sponsored visas and told us they had provided additional support where appropriate such as help with finding nearby accommodation. The provider had previously celebrated different cultural festivities with staff.

Despite the lack of formal supervision by leaders, staff felt supported and told us they received the support they needed. Staff spoke of feeling valued and working well together as a team. We saw evidence of leaders making reasonable adjustments for staff members, for example in relation to religious practices and commitments to personal caring responsibilities.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, evidenced by action not always being taken when risk had been identified in the care home, for example in relation to medicines.

The service had a lack of robust auditing schedules, and audit forms contained differing levels of details which meant some audits were not comprehensive enough to mitigate risks for people.

The service did not have a training matrix which meant managers did not have effective oversight of which staff training was overdue. When audits had not been completed by the registered manager, there was no process for the provider to identify and then resolve this, leading to poor oversight of some areas. This meant that although leaders were visible in the care home, their processes did not ensure any issues in the provision of care were identified and resolved.

Managers and staff did not always understand their roles and accountabilities. For example, we were informed by the registered manager staff who were administering medicines had completed competency assessments justifying their competence and ability to safely perform this part of their role. However, we found 2 instances where staff members’ competency records detailed during observation, they had not demonstrated the required competence for an aspect of medicines administration, in relation to asking for consent, and yet there was no record of follow up action to rectify or reassess this. This meant that staff may not have received adequate support and training on gaining consent which could put people at risk of ethical and human rights abuses.

The medicines audit completed by the registered manager in September 2025 had also noted not all staff who administered medicines were up to date with their training and competency assessments, yet no additional action was detailed. During our inspection, we identified repeated concerns with medicines which were not being reported by staff who were reviewing these records regularly. Given staff reported feeling able to raise concerns, this demonstrated staff were not noticing errors and their associated safety risks. This meant despite having been assessed as competent, not all staff understood their roles and accountabilities in relation to medicines, and the service did not have a clear process to ensure this was identified and rectified by any senior staff in the care home. This exposed people to continuing risk of harm as any errors that may have occurred in the administration of homely remedies could not be identified, meaning appropriate action could not be taken to keep people safe.

The provider understood their duty to collaborate and work in partnership. They generally shared information and learning with partners and collaborated for improvement. We saw evidence of partnership working with district nurses, occupational therapists, clinical pharmacists, community mental health nurses, a general practitioner and a psychiatric consultant, as well as community wellbeing groups and volunteers.

The care home had developed good working relationships with health and social care partners, and we received mostly positive feedback from partners. One health care partner said, “there have been a lot of staff and managerial changes [at Oak Tree Mews] in the last 3 and a half years and they need a period of stability”. Another was positive about the care home’s partnership working and said, “Over the years, any concerns identified have been addressed promptly and appropriately. The home has demonstrated a proactive approach by seeking advice and support from the wider multidisciplinary team (MDT) when required”.

We found that on some occasions, the provider had failed to appropriately share information with the local safeguarding team and with CQC, for example, the provider had not always notified CQC of notifiable events that had taken place, in line with their statutory duties. This was provided as feedback during our inspection.

The provider did not always focus on continuous learning, innovation and improvement across the organisation. Although plans to make improvements to the care home were discussed, there was an inconsistent approach to implementing plans and no evidence of prioritisation of actions based on risks or urgency. There was some recognition of risk, but this was poorly managed as identified risks which were significant were not always acted upon and mitigated. Action to identify and introduce improvements was found to be at times absent, reactive, or focused on the short term.

There were no consistent systems to discuss, record and share lessons learnt in the care home. Due to the identified gaps in governance processes, the service did not have robust quality assurance processes. The provider did not actively contribute to safe, effective practice and research. At the time of inspection, the care home was not involved in any quality accreditation schemes, awards or research.