The Oaks Care 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 inadequate. At this assessment the rating changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The service was previously in breach of the legal regulation in relation to governance. Improvements were found at this assessment and the service was no longer in breach of this regulation.

This service scored 75 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Following the previous assessment a new leadership team had been established; this included the manager and deputy and new senior operations staff. The manager told us, “The first thing I wanted to know was are we listening to staff, do we know our staff and what support is given.I just spoke with staff and asked them what their frustrations were, and I listened to everyone. Some of these I could fix completely.”

The manager had an open-door policy and told us they had explained any changes to be made to staff and how they wanted them to be involved. Staff told us of the improvements they had seen since the previous assessment. A staff member told us, “The new manager and deputy have transformed this place. [Manager] is a good people person. Morale has changed and staff feel more supported. There is a big, big improvement.” Another staff member said, “Recently it is so much improved, the vibe, the organisation. So much better.”

The senior management team acknowledged whilst improvements had been made sustaining these improvements and continual improvements were still needed.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Following the previous assessment, the provider appointed an interim manager and introduced a new operations team to support service improvement. The interim manager confirmed they had applied to register with CQC but were transparent in stating their role was temporary and would be focused on supporting the induction of a permanent manager. A whole-home approach to improvement was adopted, with the interim manager and deputy manager actively involving nurses, unit managers, and heads of departments in driving positive change. This inclusive leadership style promoted shared ownership of improvements and contributed to a more organised approach. Senior operations staff also visited the service regularly to support the improvements.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they felt confident in speaking up. A staff member told us, “Everyone works together, we discuss things and come up with a plan. We are listened to. The guidance from [manager] is outstanding. We have worked night and day to get it right and now it is so much easier. We have our own allocated residents, we meet with families, there is a purpose for everything.” Another staff member said, “I do feel confident to speak out.”

The manager told us, “I created an open-door policy and created spaces for conversation. I suggested things to staff and followed up what staff asked.”

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 service had taken meaningful steps to promote equality and inclusion within the workforce.Improved training was introduced for all staff, with additional leadership training for the management team. Policies were also updated to support flexible working and provide reasonable adjustments for staff with disabilities or caregiving responsibilities.

Within the provider information return (PIR) it was recorded. “We revised our recruitment process to attract diverse talent into our care home. Job descriptions were rewritten using inclusive language, and anonymised Curriculum Vitae (CV) screening was introduced to minimise unconscious bias. Additionally, interview panels now include diverse representation. These changes have resulted in a workforce that better reflects the communities we serve.” A PIR is a document that care providers registered with the Care Quality Commission (CQC) in England are required to complete, usually annually.

Staff told us they felt more valued and supported. A staff member told us, “I do feel supported, the manager is approachable. When I had [family bereavement] the manager was very supportive.”

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

A number of regular audits and checks were undertaken at the service to ensure a good quality of care. The management team understood their responsibilities to raise concerns, record safety incidents and concerns, and report these internally and externally as necessary.

Whilst we were made aware the interim manager was not intending to remain in the service long term. Improvements had been made to the support the service received at provider level. The group head of quality told us, “All managers have a service improvement plan, and we have access to this. We have weekly calls with teams and the quality manager will now start attending clinical meetings at the service. At the moment the operations team visit weekly.”

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The service demonstrates strong partnership working with external professionals and agencies. Staff reported regular involvement from the GP, dietician, speech and language teams, tissue visibility nurses and occupational therapists.

The local hospice team was actively involved in end-of-life care for people, including those recently registered or prioritised for support. This collaborative approach ensured continuity and quality of care for people with complex needs. A professional told us, “When I have visited the care home, staff are generally open to guidance and willing to implement strategies recommended to support individuals’ communication and/or swallowing needs.”

Staff described effective communication and joint working with the local authority, particularly in safeguarding matters. For example, safeguarding referrals were sent directly to the deputy manager by unit managers, and notifications were sent to CQC as appropriate. A professional said, “The manager and deputy manager have been communicating effectively with our team and with the others, such as Organisational Safeguarding Team. The home has been receptive to feedback and open to support from the professionals.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Since the previous assessment, there has been a clear focus on reflective practice and upskilling staff. For example, the manager had introduced reflective lessons learned sessions following incidents.

Staff told us their learning was encouraged and supported. Supervisions were used to reinforce best practice and share lessons learned. The service had implemented daily flash meetings to improve communication and ensure all staff were aware of current priorities and people’s needs.

Innovation was also evident in the way the service personalised care and activities. The introduction of “Resident of the Day” ensured a focused review of individual needs, preferences, and wellbeing. Activities were introduced based on people’s feedback.

The manager had an open-door culture where staff were empowered to contribute ideas and raise concerns. Staff from all departments, including maintenance, activities, catering and housekeeping, were now involved in quality improvement planning, reflecting a whole-home approach to innovation and service development.