The Oaks Care Home

On this page

• 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.

This is the first assessment for this newly registered service. This key question has been rated outstanding.

This meant people’s outcomes were consistently better than expected compared to similar services. People’s feedback described it as exceptional and distinctive.

This service scored 88 (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 made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

People’s needs were assessed prior to them moving into the home. These assessments were face to face where possible and this information was used to assess whether the provider was able to meet the person’s assessed needs. This information was then used to develop personalised care plans. Care plans reviewed were tailored to each person and included detailed information about health needs, personal history, preferences, and included details of the people important to them. Care plans and risk assessments also considered people’s protected characteristics, as identified in the Equality Act 2010, including gender, age, culture, religion, sexuality, ethnicity, and disability.

Care plans were reviewed monthly, or more frequently when changes occurred, ensuring they remained accurate and reliable for staff to follow. Staff told us these plans were essential in helping them deliver safe, appropriate, and person-centred care. People and those important to them were actively involved in this process. One relative told us, “The manager came to meet us at home and completed an assessment. We were involved in the assessment and care plan. We were asked lots of information about how [my relative’s] needs could be met. We felt involved and listened to.”

For people at risk of falls, we observed robust and comprehensive risk assessments had been completed. These assessments considered multiple contributing factors, such as the impact of medicines, hydration levels, infection risks, and a person’s balance and gait. This approach demonstrated that the provider was proactive in identifying and mitigating risks effectively. Staff understood the importance of promoting mobility and independence while managing these risks, which aligns with the provider’s focus on wellbeing and autonomy.

Records clearly documented people’s preferences, including when and how they wished to receive support, and any cultural or personal wishes.

Overall, this evidenced that the provider was delivering personalised and safe care. Systems were in place to keep care plans current, involve people and those important to them, and manage risks proactively.

The provider always planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation. They worked to develop evidence-based good practice and standards.

The provider demonstrated full accountability for the delivery of care and ensured that, following a comprehensive assessment of individual needs, people received evidence-based care and treatment in accordance with current legislation and recognised standards. Care and support provided by staff consistently reflected best practice and incorporated the latest research, ensuring that decisions were informed by evidence rather than routine practice.

People had individualised care plans created in partnership with them and those important to them. These plans were developed following initial assessments and updated whenever new risks were identified, after changes in need, or following any accidents or incidents. Risk assessments were completed when a person moved into the home and reviewed routinely monthly and whenever the person was the focus for the day. Care plans were tailored to each person and included detailed information about health needs, personal history, preferences, and people important to them.

Staff took part in training and workshops about the Kitwood Model of Care. This is a person-centred approachto dementia support that emphasizes thepreservation of personhoodand quality of life through respectful social interactions and meeting core psychological needs. This helped them learn how to give kind, person‑centred care, especially for people living with dementia. The training helped staff by giving them practical tools to support people better. Staff told us they felt more confident in their work.

People living in the home also benefited by receiving more personalised and caring support. Staff understood their likes, history, and identity. This helped people feel more comfortable and emotionally supported.

One staff member told us, “The training made me realise the importance of placing the people I support at the centre of care and helping them to make decisions.”

The provider introduced assistive technology to improve pain assessment and management. For people who could not, or struggled to, express pain due to dementia or other health conditions, staff used ‘PainChek’ a smart application that uses a device camera and AI to analyse facial muscle movements indicative of pain. The system scores pain on a scale from 1 to 10, and pain relief was offered when scores exceeded 8, provided medication had not been given in the previous four hours. This technology ensured timely and effective pain management, reducing symptoms such as stress, agitation, anxiety, and depression. For example, 1 person living with advanced dementia was experiencing significant distress, reduced nutritional intake, and increased incidents of conflict, while being unable to communicate whether they were in pain. The team used the evidence‑based ‘PainChek’ tool to determine if pain from previous injuries was contributing to these behaviours. Assessments indicated discomfort, and following GP review, the person was prescribed a transdermal analgesic patch as they were unable to tolerate oral medication. Subsequent ‘PainChek’ reviews carried out showed reduced pain levels, and the person became calmer, more engaged, and began eating and drinking well again, resulting in healthy weight gain. With pain effectively managed, the team were also able to identify separate mental health needs and engage the appropriate support. This demonstrated that the effective use of ‘Painchek‘ as an assessment to identify unmet needs, guide clinical decisions, and improve overall wellbeing.

The home also had a ‘LifeVac’ device available, a specialist choking rescue tool designed to clear airways and known to have saved lives. This ensured staff had immediate access to emergency equipment, enabling them to respond promptly and effectively in the event of an airway obstruction. Staff had received training on how to use the ‘LifeVac’ device as part of their emergency response training, which also covered first aid and choking protocols. This meant staff were confident and competent to act quickly in an emergency, reducing the risk of harm.

The provider served decaffeinated tea and coffee as standard unless people requested caffeinated drinks. People were informed of this approach before moving into the home. The provider referenced evidence-based studies showing a correlation between serving decaffeinated drinks and a reduction in falls, as well as other health benefits such as improved sleep patterns, better balance, and coordination. The provider recognised that this simple change could significantly reduce falls, particularly for individuals at higher risk due to age, frailty, or medical conditions. For example, a person living with dementia and complex long‑term conditions had arrived at the service with frequent falls, incontinence, poor nutrition, and significant agitation. Assessment identified that his very high caffeine intake was worsening continence, disrupting sleep, and increasing his risk of falls. Working in partnership with the person and family, the team introduced decaffeinated alternatives as an evidence‑based way to reduce triggers while maintaining preferred routines. This led to no further falls, no UTIs or incontinence, improved sleep, substantial weight gain, better nutritional intake, and much greater engagement and confidence. This demonstrated how a simple, personalised evidence‑based intervention such as replacing caffeinated drinks has significantly improved a person’s health, safety, and wellbeing.

Information provided to people included research on the experiences of LGBTQ+ individuals in care settings, highlighting that some may feel ‘invisible and marginalised.’ The provider demonstrated its commitment to inclusivity by promoting its involvement with the rights charity Stonewall and informing people that it was part of Stonewall’s Diversity Champions programme. This reflected a clear dedication to fostering an environment where all individuals, regardless of gender identity or personal relationships, are respected and treated equally.

In addition, the provider used recognised clinical tools to monitor people’s health and wellbeing, incorporating these into care plans and risk assessments. For example, staff used the Malnutrition Universal Screening Tool (MUST) to identify individuals at risk of malnutrition, enabling timely interventions and support to maintain nutrition and improve overall health outcomes.

The provider always worked well across teams and services to support people. They shared thorough assessments of people’s needs when they moved between services, so people only needed to tell their story once.

The provider worked in partnership with external agencies to ensure people’s needs were met through a coordinated and collaborative approach. Visiting health professionals told us they regularly attended the home to support individuals with complex care needs, helping both the person and the provider achieve smooth transitions and successful placements. One professional commented, “All the staff are very helpful and supportive and are not afraid to raise concerns directly with the office regarding any deterioration in people’s health or wellbeing to request an on-site visit.” Another said, “We have an excellent relationship with the home and always recommend the home to other professionals.”

Staff worked closely with healthcare professionals to plan future arrangements when people were preparing to move from the home. Information gathered during assessments and care planning was used to create individual profiles, which could be shared with hospitals or healthcare providers to ensure continuity of care during appointments or admissions. This demonstrated how internal staff teams and external services worked together to maintain safe, effective care and reduce risks during transitions.

Partnerships with external stakeholders were extremely positive, as reflected in feedback we received. A visiting health professional told us, “The staff have always engaged professionally and collaboratively. They are responsive to concerns and communicate appropriately regarding peoples’ care.” The management team worked effectively with people, healthcare partners, and stakeholders to keep people safe while supporting independence and choice.

The service also prioritised seamless admissions for new residents. Family and friends were encouraged to visit, and they had access to the bistro café for hot drinks and homemade cakes and a place to sit and chat with their relative. Where external health or social care assessments were required, referrals were made promptly, and actions were followed up without delay. Staff told us they had excellent relationships with external bodies, including GPs and community services. The home benefited from a weekly GP ward round and access to the Community React Team (CRT) during working hours. This responsive service provided rapid intervention within 2 hours, aiming to reduce hospital admissions and ensure people receive care in their home environment.

Staff respected their colleagues and were keen to share knowledge and good practice for the benefit of people they supported. They had access to specialist ‘champions’ such as skin integrity guardians, hydration and nutrition leads, and moving and handling experts. These champions acted as mentors, guiding staff in their areas of expertise to ensure people received safe, person-centred care tailored to their needs. This collaborative approach within the staff team complemented the strong partnerships with external professionals, ensuring people benefited from a well-coordinated, multidisciplinary approach to care.

The provider supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support.

The management team held daily meetings with all departmental leads to maintain oversight of people’s health and wellbeing. These meetings covered a range of areas, including nutrition, hydration, medicines, pressure care and skin integrity. Senior staff escalated any concerns to healthcare professionals for appropriate action.

Staff in each household recorded the daily support provided using electronic systems, and we saw records in place to monitor pressure care and food and fluid intake. Staff were alert to changes in people’s presentation that might indicate a deterioration in health or wellbeing. Any concerns were escalated and shared during handovers to ensure continuity of care.

People and their relatives told us staff were proactive in supporting their health by arranging appointments with healthcare professionals, including opticians, dentists, and chiropodists. Visiting professionals confirmed that any guidance provided, such as instructions for medicines or dressings, was consistently followed by staff. Records demonstrated that outcomes from these visits were documented, along with recommendations for staff to implement. This included actions required where changes in people’s health conditions or mobility had been identified.

We received mixed feedback about the food provided at the home. Some people told us the meals were good and shared positive comments. One person told us, “The food is great - I can have what I want.” Another person stated, “I don’t have to wait for my meals. The staff are good and bring them at my chosen times The food is very good. They do all sorts of things on the menu. We get lots of choice.” Others expressed dissatisfaction about the meals served. One person said, “I’m not very happy about food choices” Another person told us, “I have made a complaint about the food. Nothing has changed.”

People expressed dissatisfaction with the sandwich fillings on offer. Feedback from people was shared with the management team, who confirmed that overall responses about food had been positive. However, the management team took a proactive approach to address concerns by arranging taster sessions. This included an afternoon tea where a variety of sandwich options were offered, enabling people to select their preferred fillings. These choices were then incorporated into the menus to reflect people’s preferences.

We found systems in place to gather feedback about meals, and kitchen staff were knowledgeable about people’s dietary needs and preferences. They told us they were kept informed of any changes and updated when new admissions occurred. We observed efforts to make mealtimes a positive experience, with tables laid, menus available, and music playing in the background. People who required assistance were supported in a dignified and respectful manner.

Staff used handheld devices to record care and support throughout the day. Food and fluid charts detailed what was offered and consumed, with clear indicators for those requiring additional support or special diets. These records were regularly reviewed to identify any changes in weight, and appropriate action was taken where needed. Instances of weight loss were reported in home-level meetings with senior staff and discussed further in governance meetings with the senior leadership team to ensure oversight and timely intervention.

The provider monitored all people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they fully met both clinical expectations and the expectations of people themselves.

The provider actively monitored all aspects of people’s care and treatment to drive continuous improvement. Outcomes were consistently positive and aligned with both clinical standards and the expectations of people themselves. Staff and management participated in daily management meetings where any changes in health or wellbeing were discussed, recorded, and acted upon.

Relatives confirmed that staff identified and responded promptly to changes in their family members’ health. Regular care plan reviews ensured the management team maintained full oversight of each person’s health and social care needs. People and their relatives were involved as partners in care, which was reflected in the feedback we received.

We found that monitoring charts, including those for bowel movements, fluid intake and output, catheter care, and blood pressure checks, were consistently completed and aligned with set targets. People’s weights were monitored monthly, and where concerns were identified, timely referrals were made to the GP. Nutritional and hydration needs were assessed and met through appropriate care planning and ongoing reviews.

People had regular reviews of their care to monitor changing needs and support the retention of skills. Staff took prompt action to escalate concerns about potential deterioration to healthcare professionals for additional support. For example, when 1 person became distressed and uncertain about a medical procedure, care companions initially provided reassurance. When this was not effective, a healthcare professional was called to explain the procedure and available options in detail. This approach helped to calm the person and enabled them to make an informed decision. The person chose not to proceed with the procedure after being supported to understand and weigh the information, and the decision was respected by professionals and the provider. The provider implemented ongoing close monitoring to ensure the person’s safety and wellbeing.

We experienced firsthand how staff responded promptly and effectively when a person’s presentation changed. Concerns were escalated through multiple staffing levels, and effective use was made of the clinical monitoring tool NEWS (National Early Warning Score) to inform decision-making. Emergency services were contacted without delay, and a second call was made when the person’s condition fluctuated. Staff prepared a full transfer pack to support safe hospital admission and worked closely with the person’s family.

The provider shared examples of how they supported people to achieve positive outcomes that significantly improved their quality of life after moving into the home. These included improved sleep patterns, reduced reliance on medication, strengthened relationships, and increased participation in activities. For example, a person living with multiple long‑term conditions became distressed about their appearance and restricted their food intake, which led to unstable blood glucose levels, hyperglycaemia, skin infections, and low energy. The team worked with the person and their next of kin to introduce clothing in a slightly larger size, helping them feel more comfortable and in control. This reduced their anxiety, encouraged a return to balanced eating, and resulted in stabilised blood glucose, resolved infections, improved energy, renewed engagement in activities, and better overall wellbeing—demonstrating how personalised monitoring and partnership working can significantly improve outcomes.

Professionals told us that staff worked collaboratively with them to develop strategies that enabled people to remain in the home with the right support and interventions. One professional told us, “We are always happy to recommend The Oaks at management meetings for complex placements.”

The provider told people about their rights around consent and respected these when delivering person-centred care and treatment.

The management team worked within the principles of the Mental Capacity Act 2005 (MCA). The MCA provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA).

People told us staff gained their consent before providing support. One person said, “I make all my own decisions like when to get dressed. I’m going to have a shower later and get dressed.” Another person told us, “They do cover me when I need to be, to protect my dignity and they draw the curtains. I don’t know why though no one can see in here.”

We observed staff knocking on doors prior to entering people’s bedrooms and heard staff seeking consent when completing personal care tasks.

Where people required assistive technology or equipment to maintain their safety, we found that best interest meetings had been recorded to demonstrate agreement and decision-making. For example, stair gates were fitted to some bedroom doors following appropriate risk assessments and best interest discussions. A relative explained, “I agreed to the gate. It’s not to stop [my loved one] going out of the room—they can’t walk anyway—but to prevent unwanted guests entering the bedroom.”

A relative told us they felt reassured that their loved one’s medication was administered consistently. They explained that, although the person sometimes refused tablets, staff had implemented a covert administration plan that was appropriately authorised and documented. This ensured the person received their prescribed medication safely and in line with professional guidance. The relative said, “[My loved one] started to refuse medicines, as they could not consent to them. They are now given in food, and that has all been signed off. That is so she doesn’t know about them. She always gets them here; she didn’t at her last place.”

Staff understood the MCA and the impact this legislation had on their role. They confirmed they had received training in this area.