Oak Tree Mews

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question Requires improvement. At this assessment the rating has remained Requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

The service was previously in breach of legal regulations in relation to safe care and treatment and consent. The provider has remained in breach of the legal regulations in relation to people’s safe care and treatment. We identified a further breach of regulation at this inspection in relation to dignity and respect.

Improvements were found at this inspection, and the provider was no longer in breach of the regulation relating to consent.

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.

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

We saw evidence based assessment tools were not used appropriately to assess people’s health risks or to monitor for further risk when people’s health deteriorated. In February 2026, 1 person had been assessed as at risk of pressure ulcer development using a nationally recognised assessment tool. They had subsequently lost weight and their health had deteriorated. However, at the time of this assessment the assessment tool had not been reviewed since February. This meant risks associated with a decline in this person’s health had not been appropriately assessed to ensure, where required, changes to their care were made to address any increases in risks to their health.

Evidence based care was not always delivered. One person had a risk assessment in place for being at severe risk of choking. This risk was due to being sick when eating certain types of food. There was no detail on foods identified that had caused this reaction so they could be avoided. Despite this identified risk there was little recorded in the way of managing this risk

People were not supported to make choices about what they ate. We found what was important to people was not always a priority or consideration. One member of staff said, “I’m a good cook but there’s not much point cooking fancy food if they can’t remember what they’ve had or even if they’ve have had lunch.” This comment demonstrated a complete lack of respect for people’s choices and disregard for people’s dementia diagnosis. When describing people’s eating habits this staff member used inappropriate, offensive and derogatory language which was both insulting and abusive about the people they were supporting. We raised our concerns about this with the provider.

One person told staff they could not eat what had been served, so staff removed the main meal, did not offer an alternative meal and served the person with a pudding. This meant, on this occasion, this person was not provided with a main meal

Some improvements had been made to the management of people’s nutritional needs. Allergies and health conditions relating to people’s diet were now recorded There were no specialised nutritional needs at the time of this assessment. The kitchen staff member was aware of people’s dietary needs and had this information correctly recorded and available to them. The provider had also recognised further work was needed to ensure the availability of fresh food.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

We found there was a continued lack of information for staff regarding the monitoring and support needs of people who required additional support or who had specific health needs. This meant there was a lack of guidance for staff on how to safely meet these people’s needs. Three people with diabetes had inaccurate information in their care plans. This meant in an emergency situation staff did not have the correct information to enable them to support these people safely. This put these people at risk of increased harm.

People were not always supported in ways that promoted their health and wellbeing. We observed poor care interactions that did not promote good outcomes for people or demonstrate respect for people as individuals. We arrived in the home at 9.30am and identified 9 people who remained in the same position from this time until lunchtime. One person was not supported to reposition until 1.23pm. This person was on repositioning support at night as they had been identified as at risk of tissue damage and had just recovered from reddened marks on their heels.

Monitoring did not identify where people’s ability to make personal choices was not supported. We observed a person’s choice about a drink being disregarded. We reviewed a shower allocation chart which recorded who was allocated a shower on a particular day. Staff told us how they used this and confirmed 2 people had received their allocated shower that morning. The registered manager was aware of the record but not aware of how staff were using it. They had not identified this lack of person centred care when reviewing people’s care records or care delivery.

People were not always supported appropriately to take part in beneficial activities to aid and improve their health and wellbeing or in ways that were meaningful to them. Communication around activities did not support choice and staff told us they fitted activities in around care. We observed an exercise activity led by 2 staff members. This took place in the lounge area, it lasted 5 minutes and was undertaken in an undignified and disrespectful manner. People were not asked if they wanted to take part and 2 people seated on chairs facing the opposite direction were not invited to join in. Staff told people they were going to do ‘exercises’ and no music was put on to help stimulate people’s interest. Staff proceeded to call out people’s names, and they were told to put their arms in the air. At this point a member of staff took a photograph of the people for the care home’s records and both staff left. One person still had their arms in the air but eventually lowered their arms when the effort of keeping them up became too much. Another person was observed copying this person’s movement. We observed staff sitting down 5 minutes later using the service’s iPad and neither returned to tell people the activity was over. This attempt at a healthy activity was poorly delivered by staff who needed further training and understanding on the potential negative impact this had on the older people present. The activity was upsetting to witness, and people were left confused without having gained any real benefit from staffs’ involvement.

Some staff demonstrated a caring ethos towards people and were checking on 1 person regularly who had experienced a recent fall to ensure they were comfortable and had everything they needed. Staff told us that communication had improved with a staff member commenting, “We do more meetings now and communicate better, it’s something we have always done but now we are also doing it more to be updated and have a group chat to keep updated.”

We did not look at Consent to care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.