Oak Tree Mews

Ratings

• Overall

  Requires improvement

• Safe

  Inadequate

• Effective

  Requires improvement

• Caring

  Good

• Responsive

  Requires improvement

• Well-led

  Requires improvement

Our view of the service

Dates of assessment: 11 and 12 May 2026. The service is a care home without nursing for up to 20 people some who were living with dementia. There were 14 people living at Oak Tree Mews at the time of our assessment.

We undertook this targeted assessment to check whether the Warning Notices we previously served in relation to Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. The overall rating for the service has not changed following this focused assessment and remains Requires Improvement. The rating for the key question for safe has changed to Inadequate. We use focused assessments to follow up on Warning Notices or to check concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about.

We found improvements continued to be required in many areas of oversight and governance including medicines management, infection control, staffing, culture and managing specific health needs and risk. There had been a failure to take timely action to ensure people received a safe service.

We found multiple instances where identified risks were not safely mitigated by leaders to keep people safe. This included risks around falls management, preventing the risk of infection spreading within the home and addressing poor practice amongst the staff team. There was evidence of a poor underlying culture, this was demonstrated in a lack of choice and respect given to people to promote person led care. The language used by some staff members was inappropriate and had the potential to be emotionally damaging to people living in the service. Leaders were unable to provide assurances that they had robust oversight of possible risks to people.

Improvements had been made to mental capacity assessments and Deprivation of Liberty safeguard processes; ensuring people were not detained within the care home unlawfully. Assessments were in place and evidenced decisions were made in people’s best interests. Further improvements had been made to the care required by people who were at risk of developing pressure ulcers.

The provider had made improvements to ensure statutory notifications were made in line with regulatory requirements when appropriate.

During this assessment, we reviewed the 6 breaches of regulations that the provider was in receipt of. The provider continued to be in breach of 4 of these regulations, relating to people’s safe care and treatment, good governance, safe premises and equipment and changes to statement of purpose. The provider had met 2 breaches of regulation relating to consent and notification of other incidents. However, at this assessment we identified a further 2 breaches of regulation in relation to staffing and dignity and respect.

We are taking further regulatory action against this provider in response to the concerns found at this assessment. In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.

People's experience of this service

Not everyone living in this service was able to speak with us directly or express their views. At this assessment we gathered people’s experiences through spending time observing their day and speaking with some people and relatives.

We saw some poor care being delivered to people in relation to activities, meal choices and being left in potentially uncomfortable positions for extended periods of time. Some staff did not demonstrate respect or value for individuals when they spoke about people living in the service and there was limited engagement shown towards people when staff sat with them. However, some staff members were observed to know people well and were seen to be caring in their interactions.

Relatives had mixed views on improvements that had been undertaken since our last assessment. Comments included, “No changes since last time. No new residents, very quiet. A change in atmosphere, seems quite flat” and “It’s cleaner. There’s been a bit of decorating. Had a chap in doing painting. Curtains are working now.”