Oak Hill Mansion

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 service. This key question has been rated 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 71 (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 provider had positive goals for the service. Leaders made sure that staff shared the same vision in different ways such as during recruitment, training and team meetings. The owner and manager promoted an open-door culture, and people, relatives and staff spoke positively about them. A relative told us, “The owner is absolutely lovely and always pops his head in and has a chat. He is so very thoughtful with everyone. I wouldn't want [relative] to be anywhere else, I’m so glad we found this place.”

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.

The provider addressed performance issues and recently appointed a new manager with the right skills, knowledge and experience to lead the service effectively. We received positive feedback about managers. A relative said, “The home has really improved with the change of manager. It is now comfortable, upbeat, progressing, activities are planned, and more stability in the staff group.”

The provider fostered a positive culture around speaking up.

Although we did not see a whistleblowing or freedom to speak up policy during the assessment, the provider said they would put 1 in place immediately. Staff told us they felt able to speak up, that they felt valued and that they would be listened to. Staff gave us examples of where the provider responded to their concerns straight away, such as environmental issues.

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.

There were appropriate policies to support workforce equality and diversity. Staff said they had no concerns.

The provider did not always understand some of their responsibilities regarding governance. However, the provider recently appointed a new manager to address gaps, and their registration with the CQC was in progress. There was evidence that governance had improved.

Some historic statutory notifications had not been made; the new manager had rectified this.

A new schedule of audits had recently commenced prior to the assessment and was being embedded to make sure outcomes were monitored and improvements made.

The new manager had a good understanding of risk and put in a system for performance monitoring and regular safety checks of the environment.

Some issues we found during the assessment such as for medicines management, had already been identified by the manager with plans in place to address.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

The provider had links with the local community such as faith groups, shops and cafes. Volunteers from the community visited the home such as military veterans and helped people celebrate important anniversaries.

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.

The manager planned to undertake their level 5 in leadership and development diploma, and the provider was supportive of all levels of staff completing further learning to supplement their knowledge and skills. The manager changed practice following learning from incidents including the adoption of a diabetes protocol.