Oakdene Rest 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 Good. At this assessment the rating has changed to 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 good governance.

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 service had a clear shared vision and strategy. The service vision and aims were described for people in the service brochure before they chose to move to the service. The focus in the service was to create a homely environment, and reminders were displayed to ensure staff remained aware Oakdene Rest Home was people’s home. Staff held this value at the forefront of their approach, and this was reflected in feedback from people and relatives. For example, a relative told us about when a person had stayed in hospital and had been asking to go home. When they arrived back at the service the person told their relative and staff, they were so happy to be home. Staff were very pleased the person was back and made the person food they liked.

The management team promoted a positive and open culture that was shared with staff. The culture of the service was discussed during staff meetings and staff reported a good culture. A staff member told us, “I am proud of my job.”

Relatives commented on the open-door policy and approachable management. A relative said, “[Registered Manager] is professional, efficient, and keeps you informed."

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. They did so with integrity, openness and honesty. People and relatives were happy with the service provided and were complimentary of the registered manager and staff team. Staff were also positive about the management team and felt supported by them.

However, the management team had not always been supported to carry out their roles effectively. The service had started using an electronic care planning system but had not had the training required to operate the system effectively. The existing quality assurance systems had not been operated effectively and had not identified the issues found during this inspection. The registered manager accepted the issues we found during the inspection and was eager to continue to learn and develop in their role. They welcomed the assessment as a learning experience.

The provider had fostered a culture where people felt they could speak up. Staff told us they felt confident to raise concerns and understood whistleblowing procedures. Staff said, “If I [have a concern], I go to management. If it was not addressed, I go to CQC.” Posters with safeguarding and CQC contact details were displayed in the service.

People and relatives also felt able to raise concerns. A relative said, “I have never [needed to raise concern] but I would if I honestly thought it was necessary. You would have to for [people’s] safety…I honestly do think it would be acted on. I believe [Registered Manager] does a good job."

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.

Ensuring workforce equality, diversity and inclusion began in the provider’s recruitment processes. There was an equal opportunities policy in place and equality, and diversity questionnaires were completed. Staff told us they felt the management team supported their protected characteristics. For example, rota changes to support caring responsibilities. Staff completed equality, diversity and inclusion training as part of their mandatory training to aid their understanding.

The provider had not always had clear responsibilities, roles, systems of accountability or good governance. They had not always acted on the best information about risk, performance and outcomes.

Governance systems were not effective. Audits failed to identify issues with medicines, risk assessments and care records we found during this assessment. For example, diabetes and seizure care plans lacked critical detail, and medicines had not always been well managed.

Staff recruitment practice had not always been robust with some gaps in employment not explained, and some risk assessments for some staff were missing until raised during inspection. The provider had failed to identify staff had not all of the necessary training required to carry out their roles. These gaps placed people at risk of harm.

Records of daily care and monitoring were not always complete to demonstrate staff interventions when people’s health deteriorated. When daily records did not show people’s care needs were being met as care planned this had not been identified by the management as some areas of care were not reviewed as part of the quality assurance processes.

Following the inspection the management team carried out lessons learnt and held meetings with staff to discuss areas for improvement. Risk assessments and care plans were updated, gaps in recruitment and staff risk assessments implemented, staff training was booked and some was completed, and changes made to the hand over process.

The service was in the process transitioning to electronic care planning. The management team had not received additional training to support the transition and were not aware of how to use some of the systems monitoring features to maintain full oversight of the care being delivered. The registered manager organised additional training for the system following the inspection. The provider and management team met following the inspection to review their governance systems and processes. They introduced some new audits to maintain better governance at the service. We will check these at the next inspection.

The service worked closely with health professionals and maintained community links. People were supported by necessary health and social care professionals when required such as district nurses, chiropodists, opticians and social workers. Relatives felt involved and informed about the service. A relative said, “They are very good at communicating and involve us in decisions.” Visits took place without restrictions and residents enjoyed activities and outings.

The provider had not always focused on continuous learning, innovation and improvement across the organisation and local system. They had not always actively contributed to safe, effective practice.

While leaders acted promptly on feedback during the inspection, improvements were reactive rather than proactive. Lessons learned were documented, but further records reviewed such as audits completed after feedback was given, still did not pick up on where improvements were needed. Following feedback during the assessment some changes were made such as changes to handover process and staff training was completed. Other changes were planned such as to improve use of the electronic care planning systems and quality assurance processes. We will check these have been embedded at the next inspection.