Three Oaks Residential 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 requires improvement. At this assessment the rating has 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.

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.

The registered manager was promoting an open and inclusive culture within the service. They had an open-door policy for people who lived there, visitors and staff. Throughout the inspection we observed a culture of teamwork and that staff had time to engage with people. This was reflected in the feedback we received from people and their family members. For example, a person’s relative told us, “They know what they’re doing. It’s a caring environment. They respect the individual.”

Staff received supervision and appraisals and said they felt well supported by management. Staff said the culture within the home had improved due to the registered manager and deputy manager. Staff also told us, “The managers are hands on when needed and the team all help each other.”

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.

People and their relatives knew the registered manager’s name and said they felt the home was well managed. Their feedback included: “If you have a problem, you can go and talk to her. If I have a letter, I’m not sure of, I take it to her. She’s always there.” “It all runs smoothly” and “She’s very engaging. She’s lovely with the staff group…She supports people, but she also manages and gets things done. It’s good she’s like that; it’s how it should be.”

We observed the management team worked closely and effectively together. Discussions with the registered manager, deputy manager and senior care staff all demonstrated a clear understanding of their roles, and a passion for improving the lives of people. Staff told us that the management team were supportive. Staff comments included, “They’re such great support. (Registered manager and deputy manager) always make it work. They’re a great team.”

Senior care staff told us about how their role was changing to embrace more responsibility in line with the registered manager’s vision for developing the service. The registered manager told us of plans to pursue further professional development.

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

There were systems and processes in place to encourage and respond to feedback from people using the service, staff and external stakeholders. The registered manager and staff promoted an atmosphere where people felt able to speak up.

Staff were confident about expressing themselves and raising any concerns to the management team. Team meetings were used to share ideas and suggestions as well as learning from any concerns or incidents.

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.

Staff told us they were all treated fairly. The registered manager had introduced e-learning, which provided opportunities to adjust ways of learning to overcome possible barriers for individual staff, such as language and dyslexia. For example, where some staff may find it difficult using written work sheets, the e-learning provided audio and visual support. Relevant training included mental health, positive behaviour support, learning disabilities, gender sexuality, diversity, and promoting positive wellbeing in the workplace.

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.

There were systems and procedures for monitoring the quality and safety of the service. The provider commissioned an external consultant to carry out regular audits of the service, and we saw records of these. The registered manager reviewed and discussed the findings of these reports with the consultant and took appropriate actions where recommended.

During the inspection, the registered manager showed us additional auditing tools they had identified, which will support the further development of monitoring of patterns and trends, such as people’s weights and falls. Following the inspection, the registered manager informed us they were adding an actions and outcomes section to their quarterly action plan. This will help provide an overall picture of planned and completed service improvements.

The registered manager was in the process of implementing regular meetings of senior care workers to further develop role expectations and accountabilities.

The registered manager was clear about their legal responsibilities and notified the commission appropriately. Where issues were brought to their attention, the registered manager investigated these, and informed relevant parties as needed.

We received positive comments from health and social care professionals who provided feedback. One told us they felt the home was very well led by the registered manager and deputy manager. They said “It is a place of safety. It provides effective care and responds well to people’s needs…I would give them 5/5.” Another commented, “We have nothing but good things to say about Three Oaks residential home…We have a very good working relationship with them and have never had to give any negative feedback or raise any concerns.”

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 provider completed surveys and encouraged people to provide feedback. There were visual displays of survey results in the home, showing a high level of overall satisfaction with the service. The registered manager was further developing the activities on offer in response to feedback. Community involvement was also being further developed.

Records showed the provider worked closely with external agencies. We received positive feedback from health and social care professionals, who confirmed the service provided safe, effective, compassionate and high-quality care. A health care professional told us, “(registered manager) in particular we have a very good working relationship with.”

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.

People told us about their involvement in residents’ meetings. Their comments included, “We had one not so long back. They wanted to put paving slabs in the garden so everyone can get about and get some benches to sit on.” “We’re always invited. They do a progress report. I think what they promise, they provide.” “They talk about what they’re doing and what they’re going to do. Anyone can say what they want to.”

We saw evidence of ongoing investment in and improvements to the home environment, including upgrading WIFI, new adjustable lighting, and bathroom refurbishment. We heard from the registered manager and saw records of plans and actions to integrate the service more with the local community.

The provider had systems in place to report, investigate and learn from incidents and accidents. Investigations were undertaken following incidents, and appropriate actions were taken in response.