Archived: Langley Oaks

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• 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

This service was previously rated good. This key question has been rated good overall. However, when we considered the quality of the provider’s governance, we identified gaps in documentation and record keeping which meant we could not be assured they were maintaining accurate records.

The provider was in breach of legal regulation relating to governance. We have asked the provider for an action plan in response to our concerns.

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.

Senior leaders had a shared strategy and were working together to enable staff to access training, policies and procedures to support them to provide good quality care.

There had been significant gaps in staff supervision which is noted previously in this report; however, this had been identified by managers and steps taken to improve the frequency and quality of supervision. The registered manager was committed to fostering a learning culture and had introduced monthly staff meetings to strengthen a shared vision and culture and a shared responsibility and commitment to continual service improvement. Managers felt supported by the senior leadership team through their supervision and management meetings.

The provider had inclusive leaders 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.

Managers were well regarded. A relative said, “The leadership there is excellent. I feel that any complaints would be taken seriously.” The managers are very approachable as well.” A relative told us, “The managers are great, very helpful.” Healthcare professionals told us they had a positive working relationship with the managers and the staff team.

Staff said they had good working relationships with healthcare professionals, comments included, “Yes we work well together, we work as a team to support people as best we can” and “They come here regularly to check people’s health and if we have an urgent need they respond appropriately”.

The registered manager was an experienced healthcare professional and had a good understanding of the needs of people and how these should be met through the provision of safe, high quality care. Staff told us managers were experienced and supported them in their roles.

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

People’s feedback indicated they had no concerns about speaking up if they needed to. A relative said, ‘There have been absolutely no issues. I know that this home would take complaints seriously” and another relative told us, ‘There are no issues with the home. The staff and the new manager are all very good and will listen to anything I say.” The provider encouraged both people and staff to rate their satisfaction and provide feedback in the annual feedback surveys.

The registered manager told us, “I encourage staff to speak up, and I am working on my visibility, I have an open door, I send group messages and have been holding monthly team meetings. If staff can’t attend, they have access to the minutes. I have a speak up champion who can talk to either me or the deputy manager. We also have an anonymous whistleblowing policy, so issues can also be raised directly with Care UK.”

Staff were positive about the leadership team and felt they could speak up and their voice would be heard. A staff member gave an example of when they had escalated an issue to senior leaders, and had felt comfortable doing so.

The provider valued diversity in their workforce and in the home. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them, and the people who lived in the home.

People thought the home valued diversity and celebrated this in the home. A relative said, “There was a Jamaican Independence Day event recently when [my relative] danced his socks off. All the flags around in the home represent the different countries that the residents hail from, which I think is a lovely touch.” Other relatives told us, “They do a lot of cultural activities, such as speaking with [relative] in their first language” and “About every six weeks there seems to be a big celebratory event now, for example, the VE Day celebration, and the Asian celebration with spicy food.”

We observed different cultures being celebrated in the artwork and activities. The staff team was diverse and inclusive.

The provider did not always maintain accurate and timely records to inform their governance processes. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider had multiple (digital and manual) processes that were difficult for staff to understand. The provider used these for both organisational governance and to measure the service’s performance. As a result, we found this led to recording gaps, and it was not always easy to establish if all actions were identified and consistently taken to address all the risks these different processes identified. For example, we reviewed 2 quality performance reports from May and June 2025, evidence of any discussions, actions, outcomes and service improvements was not completed or signed off by the leadership team. This meant we could not be assured actions had been identified and acted on to reduce the risk of harm. We reviewed the provider’s “Action Log Go Audit” from May to August 2025 and found it did not include the details of risks or the actions being taken to mitigate risks. We could see it was a live document, which was being used to track actions and record when they were completed. However, the failure to include details of the risks and the actions being taken meant we could not be assured it included all actions identified from accidents and incidents, analysis, audits and checks.

This was a breach of Regulation 17 Good governance of the Health and Social Care Act 2008 (regulated activities) Regulation 2014

Staff told us they would feel more supported if there were more care staff on each shift. We observed during our site visit there were times when there were not enough staff available to meet people’s immediate needs and prevent the risk of harm. The provider used a dependency tool which assessed people’s needs and informed staffing levels based on those needs. We discussed this in detail with the provider’s leadership team to ensure we understood its application given the feedback and our observations. The provider’s view was that it was an effective tool and current staff numbers were meeting people’s needs. We reviewed care records and 2 people’s care records indicated higher support needs, for example, requiring supervision to reduce the risk of choking at mealtimes. However, this was not reflected in the dependency tool. This meant we could not be assured the dependency tool was always effective in determining staffing levels because it did not accurately reflect people’s support needs.

Given the inconsistency and gaps in record keeping we could not be assured the governance processes were always used effectively to minimise the risk of harm to people. The registered manager was aware of this and was addressing it by manually updating the service improvement plan and allocating staff actions and deadlines for these actions to be completed. We will monitor the progress of this work and will review it either at the next inspection or earlier if the need arises.

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 facilitated access to a hairdresser on site, which people appreciated. A relative told us, “The hairdresser comes every week on Friday, and I ensure that my [relative] has a nice hairdo each week, which helps to lift her mood and maintain a positive self-image.’

The provider had other care homes in the area and managers engaged with other home managers to share learning and improve outcomes through a quarterly assurance meeting and monthly managers forum. We saw the provider shared information and worked with other professionals regularly to ensure services worked together. For example, admission of new prospective residents was pre-planned with professionals and relatives to alleviate any distress for people during the move.

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. The provider had procedures in place regarding reporting and learning from when things went wrong. The registered manager told us they carried out regular audits and checks of the quality and safety of people's care. This included checks of the environment and equipment used for people's care and checks of medicines and care plans. Regular checks were also made of any accidents and for people's health and nutritional status and any related incidents, such as weight loss, infection or skin sores. This helped to identify any trends or patterns to inform any changes that may be needed to improve people's care.

The service’s development plans included actions that that had a target completion date and identified the staff member responsible for them.

During our inspection, we found the provider actively fostered a culture of learning, improvement and openness. Poor practice was addressed promptly to ensure staff learnt and could correct it quickly for their self-improvement, which provided better outcomes for people. Feedback from staff was also encouraged. Staff told us they were asked to provide their ideas for improvement during team meetings, reflective practice and handovers for the registered manager and deputy manager to act on. The registered manager said, “Every meeting, handover and/or clinical meeting, we discuss ways we could improve”.