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.

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

This meant service leadership was exceptional and distinctive. Leaders and the culture they created drove and improved high-quality, person-centred care.

This service scored 93 (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 very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities.

The provider shared their mission statement with people and staff: “To provide compassionate, heart-centred care that enriches the lives of those who live and work in our homes.” Their vision was to create a family-like environment where people could enjoy a life well lived, supported by their loved ones and the wider community. Discussions with staff and the management team reflected their commitment and passion to fulfil this vision. People told us they enjoyed living at the service. One person said, “They are all kind and caring, just the way they are with me is kind. They are all just lovely. Both the day and the night staff.” Another person shared “The staff are all really kind. I have a good laugh with them all. We have lots of banter. I am so happy here.”

The management team told us they had changed the company name to EQ Care Group to reflect its core values and commitment to emotional intelligence (EQ).

We found the service had an exceptionally positive culture, demonstrated by staff and the management team in their roles. Staff consistently told us they enjoyed working at the home, and the management team explained how they embedded the provider’s vision and values throughout systems and processes. Recruitment was focused on selecting staff who viewed their role as a vocation rather than just a job. The provider placed great emphasis on investing in and developing staff who reflected the right values.

The provider evidenced how continuous collaboration and learning was a core focus of their strategy. We found many initiatives in place to ensure people, their relatives, staff, and professionals had opportunities to express their views. The provider demonstrated a positive listening culture by acting on feedback they had received and informing and updating people of any changes they made because of this. We observed staff demonstrated an understanding of inclusive care by supporting people to overcome any inequalities they may face. Equality and diversity and human rights approaches were embedded in everything the provider and management did and was understood by all staff.People and their relatives were consistently positive about their experiences of the home and how the provider, management and staff team were approachable and how they had developed positive relationships with them.

The manager was supported by the Group Operations and Clinical Director and Chief Executive Officer (CEO) who also visited the home during the assessment to further support the manager and assist the inspection team.

The provider had exceptionally 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 always did so with integrity, openness and honesty.

There was a strong management team with clear roles and responsibilities. The registered manager and deputy manager had both worked at the service since it opened in July 2023 and had developed a relationship of trust and shared objectives. The registered manager and deputy manager were supported by the Group Operations and Clinical Director and Chief Executive Officer (CEO). They were all very motivated to improve and develop healthcare provision both inside The Oaks and in the wider community. One healthcare professional told us, “The management team at The Oaks are amazing and know people and their needs and are supportive to staff.”

Staff told us managers were visible and supported them to provide high standards of care. One staff member told us, “I know the [registered] manager well. If you need to go and see her about something, her door is always open.”

People and relatives knew who the managers were and expressed confidence in their management of the home. One person told us, “The managers are caring and ask how I am doing.” Another person told us, “I do know the manager she came up here this morning. I think she runs the home really well.”

The management team were knowledgeable about the people living at the home and their individual needs. We observed daily meetings which were held where key information was shared to ensure everyone in all roles at the service were kept up to date and received essential information. External professionals described the management team as approachable, supportive, and responsive. Professionals reported that managers were always willing to offer assistance and engage constructively when seeking solutions.

The management team was also commended for maintaining positive and effective working relationships with partner agencies. One healthcare professional shared feedback stating, “They are a great team to work with, and will pick up the phone to request guidance and follow instructions provided.” This demonstrates a strong commitment to collaborative practice and proactive communication with external stakeholders.

This outstanding leadership created a culture of openness, trust, and respect, where people, families, and staff felt valued and empowered. The provider and management team’s visible presence, and commitment to person-centred care ensured the home was not only well run but also a warm and welcoming place for all.

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

The provider had policies and processes in place to support staff to speak up, including team meetings and one-to-one supervision sessions. Staff were made aware of the provider’s whistle blowing policy during their induction. Managers were described as having an ‘open door’ approach and were available to staff throughout the day.

We observed that managers were visible and approachable, and staff told us they felt comfortable raising concerns. They said leaders listened to their views and acted on feedback when required, which helped create a positive and supportive culture.

Annual surveys were sent to relatives, staff, and professionals, and feedback was sought from people living at the service. Visitors were asked for feedback through the electronic sign-in system. All feedback was used to drive improvements in the home. Regular residents and family meetings were held at the service. One person told us, “I go to all the residents’ meetings. I like to tell them what I think.”

The provider strongly 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 provider made thoughtful and practical adjustments to create an inclusive, supportive, and safe workplace where all colleagues can thrive. This included adapting work allocations so staff could uphold their cultural or religious beliefs without impacting service delivery for example, supporting colleagues who are unable to provide personal care to male residents. The provider also offered structured support for neurodivergent staff to reduce overwhelm, build confidence, and tailor responsibilities. In addition, technology such as speech‑to‑text software was introduced to remove documentation barriers for colleagues who benefit from alternative communication methods. These proactive measures aimed to ensure every team member was supported in their role, able to contribute fully to high‑quality care, and empowered within a workplace that recognises and values individual needs.

The provider promoted inclusion and celebrated diversity. Staff were informed from the outset about the provider’s commitment to creating an environment where everyone, including those from the LGBTQ+ community, is respected and accepted. Staff shared that they had recently attended a Pride event, which they celebrate annually, and described feeling supported and included regardless of background. Policies and procedures were in place to uphold equality and diversity, and the provider demonstrated awareness of their duty to respect protected characteristics and prevent discrimination.

Staff had been recruited from diverse backgrounds which was representative of the local community. Staff told us how the management team were flexible and understanding of their individual needs in relation to their personal circumstances, supporting flexible working arrangements. The provider undertook risk assessments for staff with health considerations that might impact their work.

The registered manager’s open-door policy ensured all staff regardless of role, background, or personal circumstances felt heard and supported. This inclusive leadership style helped build trust and equity within the workforce. The provider invested in the development of staff and worked hard to retain them.

The provider demonstrated a strong commitment to workforce development and clinical excellence. A newly qualified nurse was supported through the preceptorship program, managed by the deputy manager, a registered nurse. This structured scheme was aimed at building confidence, skills, and competence through mentorship, regular check-ins, and competency-based training, ensuring safe integration into the team. A member of staff told us, “I felt guided every step of the way there was always someone to turn to, which helped me grow in confidence far quicker than I expected.” Another staff member said, “Yes, it is a good place to work. The things I enjoy are the people we look after. Coming to a care home, you see the people day in day out and you see the people more than your own family sometimes. When you achieve something for someone it means a lot.”

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.

The provider had effective governance systems in place to maintain oversight of the service. They used an electronic system called Radar, which supports ongoing monitoring of people’s experiences, risks, and outcomes. The registered manager, senior leadership team, and provider could access a dashboard to review data on falls, incidents, medication, complaints and skin integrity. The management team demonstrated how they used this system daily to identify missed medication, new incidents, or any gaps in care, enabling prompt follow-up with staff. The dashboard generated alerts for issues requiring attention, review, and sign off. This included safeguarding incidents when a person experienced a fall, or peer to peer incidents. Management reviewed the incident to ensure all actions were completed and future risks mitigated and learning from the incident was documented.

Records showed regular audits covering medicines, finances, and the environment. Where shortfalls were identified, appropriate actions were taken immediately. These processes demonstrated strong governance arrangements, ensuring compliance with legal requirements and promoting safety through continuous oversight and timely intervention.

During our review of people’s daily records, we identified gaps in information, with some notes being task-focused and not always reflecting people’s wellbeing. We also found staff had not consistently recorded checks to confirm that safety equipment was functioning effectively. The provider’s own audits highlighted similar issues, including incomplete documentation of tasks and wellbeing, and identified the need for additional staff training, which was being actioned.

Management addressed these concerns during team meetings, reinforcing the importance of accurate and timely record-keeping and taking proactive steps to improve reliability. For example, while staff recorded that visual checks of airflow mattresses had been completed, the system did not specify what should be checked. This was immediately rectified by updating the electronic recording system to include clear guidance. These actions demonstrate the provider’s commitment to continuous improvement and maintaining safety through robust governance and accurate records.

The management team carried out daily walk-arounds across all households to ensure people were supported appropriately, staff were fulfilling their roles, and the environment was well-maintained. Daily meetings brought together staff from all areas of the home to share key information, enabling good communication about safety updates, care needs, and operational priorities. Outcomes from these meetings were recorded and escalated to senior management and the provider where necessary, ensuring accountability and timely responses. Regular meetings at all levels strengthened governance and monitoring arrangements, providing continuous oversight and promoting a culture of safety and responsiveness throughout the home.

Senior management’s active involvement strengthened governance by ensuring clear oversight and accountability at all levels. Their regular presence enabled them to monitor compliance with quality standards, review audit outcomes, and confirm that action plans, lessons learnt etc were implemented effectively. By supporting the registered manager and clinical lead, senior leaders ensured leadership capacity was maintained, and improvements were driven collaboratively. This proactive approach demonstrated good governance, continuous learning, and a commitment to sustaining high-quality care.

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

People and those important to them told us they felt involved and listened to, with staff, the management team, and the provider working in partnership to achieve the best outcomes. Information was shared openly to support improvements in care. The provider engaged in discussions with people and their families prior to admission to manage expectations and provide reassurance, recognising how challenging the transition into care can be for both people and their loved ones.

Health professionals we spoke with were highly complementary about the home and the way staff worked in partnership with them to meet people’s needs. They confirmed the management team was supportive during quality visits, receptive to feedback, and proactive in addressing recommended actions. This collaborative approach strengthened relationships with external professionals and ensured people received safe, coordinated care.

The provider demonstrated a strong commitment to workforce development and clinical excellence. A newly qualified nurse was supported through the preceptorship program, managed by the deputy manager, a registered nurse.

In addition, the provider engaged with the University of Birmingham to explore opportunities for trainee nurses to gain practical experience in person-centred care for residents with complex needs, such as dementia. These placements combine on the job learning with academic study, creating a pathway toward full nursing qualifications and strengthening future workforce capability.

The CEO shared their active role as a non-executive director for The Outstanding Society, a community interest company dedicated to sharing best practice among care providers. This initiative offers an inclusive platform for accessing information, celebrating innovation, and exchanging ideas to improve standards of care. Through this role, the CEO connected with a network of professionals, enabling knowledge sharing, peer support, and collaborative problem-solving, which was then cascaded to the management team at the home. The provider participated in the national Vivaldi research programme, working with leading organisations to strengthen infection prevention and ensure the service remained safely open to visitors. Managers attended specialist Vivaldi training, enhancing their knowledge and supporting shared learning across the sector. This had led to improved outbreak preparedness, including the introduction of ‘Outbreak Boxes’ containing PPE and clear guidance in every household, enabling quick and effective responses. For example, the provider experienced only 1 minor outbreak in 2025, which was rapidly contained with no hospital admissions and no disruption to family visiting. This demonstrated how, shared learning, and proactive IPC measures improved safety, wellbeing, and continuity of relationships for people living at the service.

Since opening the service, the provider and management team had worked proactively to build strong, meaningful relationships within the local community. This included established partnerships with local schools, encouraging regular visits from children, and close links with local church groups to support spiritual connection and reduce isolation. The service also welcomed members of the community and local blue light services to drop in and use the café bistro for a hot drink and a chat, creating an inclusive, welcoming environment. These ongoing efforts demonstrated the provider’s commitment to strengthening community engagement, improving local partnerships, and ensuring people remain connected to the wider community.

The provider strived to ensure the home was a valued member of the local community.

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

The provider and management team demonstrated a clear commitment to continuous learning and improvement, using lessons learned to drive meaningful change across the service. Dedicated sessions were held to identify root causes, analyse findings, and implement positive strategies, supported by monthly organisational meetings that shared learning across all services. This approach led to meaningful improvements in how the home was organised. For example, following a review of peer-to-peer incidents on Floor 3, the area was divided into 2 households to better meet people’s preferences and reduce conflict. One household now supported people who enjoy a quieter pace and prefer spending time in their rooms with minimal distractions, while the other was for those who like to be active, social, and engage in conversation. Additional staff were added to the rota to support this change. Following the adjustment, the provider evidenced the use of incident analysis to evaluate the impact of the change. The review showed a reduction in incidents, demonstrating how learning from previous patterns had informed a more effective and safer approach. Feedback gathered from people living in the households also showed benefits of feeling happier, more settled, and more comfortable in their new household groupings. This reflects the provider’s commitment to using learning to drive continuous improvement and enhance peoples lived experience.

Investment in innovative tools further supported staff and improved care, including an electronic pain assessment system for people unable to verbalise discomfort. This enabled staff to identify pain accurately and respond quickly with appropriate interventions, improving comfort and supporting person-centred care.

The provider fostered a culture of continuous development through an innovative recruitment programme that measured emotional intelligence and offered bespoke training resources, earning national recognition for workplace development. Staff told us they felt empowered to share feedback, knowing it was valued and acted upon, and reported feeling supported and rewarded for their commitment to improving standards.

Effective governance systems ensured incidents and lessons learned were reviewed in ‘Lessons Learned Lab’ meetings, where staff explored new approaches to delivering excellent person-centred care. The provider also strengthened external partnerships and engaged in research to adopt evidence-based practices and advanced technology, ensuring improvements translated into better outcomes for people.

The provider demonstrated a strong commitment to learning, improvement, and innovation by enhancing end‑of‑life care through a range of recognised best‑practice approaches. This included rolling out the Six Steps to Success Programme, Soul Midwives training, and the Namaste initiative to strengthen staff skills in delivering holistic, compassionate support that meets people’s emotional, spiritual, and sensory needs. A family-friendly information booklet was also produced to help relatives understand the approach and feel more involved in their loved one’s care. In addition, all staff completed dying and bereavement training as part of induction, ensuring a consistent, evidence‑based standard of care across the service and a personalised, dignified experience for people at the end of life.