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 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 remained 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 previously in breach of legal regulation in relation to governance, notification of incidents, and failure to submit changes to the statement of purpose. The provider has remained in breach of the legal regulations in relation to governance and failure to submit changes to the statement of purpose.

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

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 Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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 purpose of this assessment was to check if the provider had met the requirements of the warning notice in relation to Regulation 12 (Safe care and treatment) Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found that the serious concerns identified at our last inspection on 25 and 26 November and 2 December 2025, had not all been acted on and areas of required improvement and unsafe care remained evident.

The leadership team had failed to act sufficiently to address concerns and to implement effective governance within this service to keep people safe. There was a lack of oversight, knowledge of requirements and understanding of how to meet required regulations. We were not assured the registered persons had the necessary skills and knowledge to run and provide a service that is safe and effective.

Quality assurance and monitoring systems were being slowly implemented however these had not been fully embedded and were not effective at identifying and addressing shortfalls. This placed people at continued risk of harm.

The provider still did not have a system in place to monitor the call bell response for people. This meant there was no robust way of assessing the length of time people waited to receive care and any concerns would not be able to be fully investigated and addressed.

There was not an effective system for recording and storing information about people’s care. Staff used an electronic system, and the management team used a paper system and the 2 were not managed to ensure they correspond with each other. Despite the services action plan stating the action to address this was completed, this was not the case, and staff were accessing incorrect and out of date information about people’s care needs including nutritional needs and falls management. As a consequence, people had been left at continued risk of harm.

The provider did not have effective oversight of the service in order to identify concerns, service shortfalls and drive improvement. We found the audit findings were not an accurate reflection of the service and care being provided to people. This meant the provider did not have was no effective oversight over the service provision in order to identify concerns, drive improvement and keep people safe.

Cleaning audits and mealtime experience audits identifies actions for improvement that were not addressed. This meant people continued to be at risk of harm and their quality of life was not improved. The audit showed this was a reoccurring theme for which no action had been taken to make improvements. This demonstrated a lack of respect and importance shown for promoting people’s choice and improving the care experience they received. Medicines audits did not identify failures to manage topical medicines and first aid supplies safely.

The registered manager told us no night checks had been completed since January 2026. This meant they were no longer able to be assured staff were completing their roles appropriately and that the service was being run safely at times when managers were not present. This put people at risk of potential harm.

The provider had failed to provide adequate supervision or probationary review to the registered manager since they started in post on 28 August 2025. There was no record of any identified support or training needs, or any formal opportunity given to discuss their role and development. The lack of clear accountabilities meant a culture had developed in the home whereby staff felt unable to raise concerns.

During the previous assessment we identified the service’s Statement of Purpose (a document which explains what needs the service is registered to meet) was incorrect. This had subsequently been resubmitted by the provider and remained incorrect despite the service’s action plan stating this had been rectified.

We saw action had been taken to ensure the service’s rating was correctly displayed on the provider’s website.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.