Oat Hill 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.

This is the first assessment for this newly registered service. This key question has been rated 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 in breach of legal regulation in relation to governance at the service.

This service scored 61 (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 service had a positive culture and staff described shared values centred on person-centred care. Staff told us leadership beliefs about providing excellent person-centred care matched their own beliefs. Staff were welcoming and engaged throughout the inspection, and the home environment supported a positive feel for people living there.

One staff member explained, “[The registered manager] has democratic leadership skills. They have all the qualities.”

Leaders were mostly supportive and committed to providing good care to people living at Oat Hill Mews. However, the responsibility of several areas of care had been assigned to other staff members for their progression and learning, and where these had fallen short, leaders had not identified this prior to the inspection. For example, the mealtime audit was being completed regularly by senior staff, however issues were identified in almost all audits for the previous 3 months regarding handwashing and leaders had not taken any action in respect of this. When this was highlighted from the inspection team, hand wipes were immediately ordered to be delivered the following day, however, this had taken intervention as a result of the inspection to make improvements.

Staff spoke positively about the registered manager, with one stating, “I think the care home is run well with a lovely manager who shares the same beliefs as me to provide excellent person-centred care.”

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

Staff told us they felt supported and encouraged to suggest improvements. Staff provided feedback openly, including ideas to enhance activities and experiences for people, such as introducing an interactive table and laptops. This demonstrated staff engagement and willingness to contribute to service improvement.

A staff member advised, “Staff are encouraged to share ideas through team meetings, supervision sessions, and open communication with managers. This allows us to suggest improvements or new ways of working that benefit the people we support.” Another staff member stated, “When I raise a concern, I feel listened to, and actions are usually taken. We are encouraged to speak up.”

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 described a supportive and fair culture, and staff felt included and supported. Staff told us they received regular supervision and felt able to contribute ideas. This supported a culture where staff could be engaged, valued and treated equitably.

A staff member stated, “I am treated well at work and feel happy to be there supporting individuals with their needs and I like working within a team.”

A leader explained, “I run health and wellbeing initiatives for the team throughout the year, recently I have done Random Acts of Kindness Day, where I gave every member of staff a small appreciation gift, I have also done Stress Awareness Day – where I asked the team to write notes to colleagues to express appreciation or gratitude to empower positive relationships, bonds and well being. We have Employee Appreciation week each year, and last year I incorporated a Power Hour on one of the days – where each person got an hour (paid) to do something for their own wellbeing – some went for walks, or a run, others for a coffee, some read a book in the garden. We run something every day of the appreciation week, doing pamper bags, pizza, posh biscuits for breaks, a management car wash (where managers washed all the team’s cars) as an appreciation gift.”

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.

We identified medicines management concerns, including out-of-date medicines being stored and used, unclear disposal and returns processes, lack of effective oversight of topical medicines recording that had not been identified prior to our inspection. Leaders also did not have effective oversight systems to assure the quality and completeness of MCA and best interest documentation, or to ensure care recording provided assurance that key care elements, such as oral care, were delivered and monitored as planned.

While leaders began to take action during the inspection in some areas, governance systems had not identified these issues proactively. This meant the provider could not be assured that audit and oversight systems were sufficiently robust to prevent recurrence and to provide consistent assurance that people received safe care.

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 worked in partnership with health professionals and families. Relatives told us the home worked in partnership with the GP and that they were involved in care planning. This supported joined-up care and continuity for people living at the home.

A leader stated, “Everyone works collaboratively and supports others.”

The service has Veteran Friendly Home Status. The service holds a ‘Fish and Chip Friday’ once a month and between 6 and 10 veterans regularly attend.

Last year, one of the leaders within the service crocheted 100 poppies and sold them with all proceeds going to the Poppy Appeal, and the head chef ran a marathon and donated the funds to Alzheimer’s Research. One of the leaders within the service was organising a charity sleepout to raise money for homeless veterans.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

There was evidence of staff being encouraged to suggest improvements and leaders taking some immediate action when concerns were raised. However, learning systems were not consistently effective at translating identified issues into sustained improvements, particularly in relation to medicines oversight and aspects of MCA documentation quality and assurance. This meant learning and improvement processes required strengthening to ensure issues were consistently identified, acted on and embedded.