Oakleigh Residential 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.

At our last inspection we rated this key question requires improvement. At this inspection the rating has remained 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 and oversight arrangements.

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 experienced significant changes in ownership and leadership. Leaders recognised the challenges facing the service and described clear priorities for improvement. Staff understood the provider’s vision and said this was regularly reinforced in team meetings.

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. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders were visible within the service and accessible to staff. Staff described leaders as approachable and said they felt supported in their roles. Leaders had the appropriate qualifications and skills in health and social care leadership to carry out their roles.

Leaders maintained oversight through regular flash meetings and team meetings, and were present within the service through daily walkarounds to monitor how care was being delivered.

The director visited the service weekly, spent time with staff and was actively involved in driving the service improvement plan.

People did not always feel they could speak up and that their voice would be heard.

The provider's culture did not consistently support openness and transparency. Some staff told us they were concerned there may be negative consequences if they raised concerns, which made them reluctant to speak up.

However, systems were in place to encourage staff to raise concerns. Whistleblowing information was displayed within the service, and team meetings included opportunities for staff to share feedback and discuss concerns.

This meant that while formal mechanisms for speaking up were available, staff did not always feel confident that concerns could be raised without fear of repercussions.

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.

Leaders promoted an inclusive approach to supporting both staff and people using the service. The workforce was diverse, and leaders recognised and respected people’s different backgrounds, needs and preferences.

Staff had received training in equality, diversity and inclusion, which supported their understanding of inclusive practice. Staff demonstrated awareness of how to support people in a respectful and individualised way.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider completed audits and quality assurance activities, including a care planning audit on 15 May 2026 which recorded the service as 96% compliant and highlighted some areas for improvement.

However, these findings did not reflect the quality and safety concerns found during the inspection. Care records reviewed during inspection contained irrelevant and, at times, contradictory information. Some records had not been reviewed since March 2026, and care plans did not always provide clear or personalised guidance for staff.

We found concerns relating to medicines management, behavioural support, diabetes monitoring, Mental Capacity Act processes and risk management which had not been recognised or effectively addressed through the provider's governance systems.

This meant we could not be assured that audit and quality assurance processes were effective in identifying risks, monitoring the quality of care or driving improvement. As a result, leaders did not always have an accurate overview of the quality and safety of care being delivered.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The provider had not fully explored opportunities to support people to access community links and activities beyond their healthcare needs. The provider could not demonstrate how community links and wider community resources were routinely used to promote social inclusion and wellbeing.

The service worked with external healthcare professionals, including GPs and speech and language therapists (SALT), to support people's health needs. However, partnership working was primarily focused on healthcare, and there was limited evidence of broader community engagement or initiatives to help people maintain connections with their local community.

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.

Systems to support learning, improvement and innovation were not consistently effective. A number of concerns identified during the inspection had not been recognised through the provider's own quality assurance processes and were only addressed following inspection challenge.

At the time of the inspection, several improvements were still in progress and had not been embedded into day-to-day practice. This reduced assurance that learning and improvement processes were sufficiently proactive, effective or sustainable.

However, leaders had systems in place to support improvement, including audits, regular meetings, service improvement plans and ongoing monitoring of care delivery. Following the inspection, leaders took action in response to concerns raised and began implementing changes. This demonstrated a willingness to learn and improve.