Four Oaks 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 assessment we rated this key question good. At this assessment the rating has remained 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 75 (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.

Staff and leaders consistently described a person-centred approach to care and demonstrated a shared commitment to supporting people's wellbeing, independence and quality of life. Staff understood the priorities of the service and were able to describe how recent improvements had strengthened care, safety and oversight arrangements. This reflected a culture where people’s needs were at the centre of decision-making and service development.

We observed a calm, organised and welcoming environment where people and their families were involved in discussions about care and support. Staff interactions were positive, respectful and focused on promoting people's dignity, choice and wellbeing. Feedback from people, relatives and staff indicated there was a shared understanding of the provider's values and expectations.

Leaders promoted openness, accountability and continuous improvement. Staff told us they felt able to raise concerns, discuss challenges and contribute to changes within the service. Leaders and staff were working together to sustain recent improvements and maintain a positive culture focused on delivering safe, person-centred care.
 

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 demonstrated a good understanding of the service, including its strengths, risks and areas requiring improvement. The registered manager and leadership team were able to describe current priorities, explain the actions taken to address concerns and demonstrate awareness of the needs of people living at the home.

Staff consistently described managers as visible, approachable and supportive. One staff member told us, "We see [the managers] regularly, [managers] always find time to speak to me." This reflected wider feedback from staff who said they felt able to seek advice, raise concerns and obtain support when needed. Staff told us leaders listened to concerns, communicated openly and encouraged them to contribute ideas and suggestions.

There was compassionate and inclusive leadership through workforce support, competency development, safeguarding oversight and regular engagement with staff. Leaders promoted a culture of openness and improvement and demonstrated a willingness to reflect on concerns and take action when issues were identified. Staff described feeling supported during a period of organisational change and spoke positively about leadership visibility and responsiveness.
 

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

Staff told us they felt able to raise concerns and discuss issues with managers and described managers as responsive when issues were highlighted. Staff also demonstrated an understanding of their responsibility to challenge unsafe practice and escalate concerns when necessary.

The provider had systems in place to review incidents, safeguarding concerns and governance findings, and there was evidence these were investigated and used as opportunities for learning and improvement. Leaders maintained oversight through governance meetings, incident reviews, lessons learned processes and action plans. Learning arising from medicines incidents, safeguarding concerns and operational issues was discussed through governance arrangements and used to support changes in practice.
 

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 recognised the importance of maintaining a stable and skilled workforce and had systems in place to monitor recruitment, training, supervision, competency and workforce development. The provider demonstrated oversight, support and training to help staff develop in their roles and maintain safe standards of care. Governance processes included monitoring workforce issues and implementing actions to support recruitment, retention and professional development.

Staff generally described managers as approachable and supportive. Staff also described opportunities for supervision, training, competency assessment and ongoing engagement with leaders.

Leaders demonstrated an awareness of recruitment and workforce challenges and had implemented measures to support staff during a period of organisational change. Workforce culture promoted inclusion, development and support, helping staff to contribute positively to the delivery of person-centred care.
 

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Leaders maintained oversight through regular audits, action plans, incident reviews, safeguarding monitoring, competency assessments and governance meetings. They demonstrated an understanding of current risks, service priorities and the actions required to maintain and improve the quality and safety of care.

Governance systems were used to monitor key areas including medicines management, nutrition and hydration, safeguarding activity, staffing arrangements, training compliance and restrictive practice. Information from audits, incidents, complaints and quality monitoring was reviewed to identify concerns, monitor progress and support decision-making. Where risks or issues were identified, actions were implemented and monitored through established governance processes.

The provider had strengthened governance arrangements following a period of organisational challenge and there was evidence management oversight had become more structured and responsive. Although some recurring themes remained, such as documentation quality, leaders had systems in place to identify concerns, track actions and reduce risk. Governance arrangements supported continuous oversight of the service and demonstrated an ongoing commitment to maintaining and improving standards of 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 service worked closely with healthcare professionals to ensure people received coordinated and responsive care. Staff sought advice, made referrals and escalated concerns appropriately when people's needs changed. These arrangements helped ensure people received the right support at the right time and promoted continuity of care.

The provider also maintained strong relationships with relatives and those important to people. In response to concerns relating to the building works, the provider consulted with relatives, held meetings, shared updates and introduced measures to minimise disruption and maintain family involvement.

Activities, social opportunities and communal facilities continued to support people to maintain connections with others. The provider demonstrated an understanding of the importance of partnership working with families, healthcare professionals and external agencies in supporting positive outcomes and maintaining people's quality of life.
 

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.

Learning from incidents, safeguarding concerns, audits and quality reviews was used to identify opportunities for improvement. Leaders were able to describe how previous concerns had informed changes to practice, including strengthened medicines controls, improved medicines reconciliation processes, enhanced nutritional monitoring and improved oversight of identified risks.

Staff told us learning was shared through meetings, discussions, competency reviews and day-to-day communication. They were able to describe improvements introduced following incidents and understood how changes to systems and processes affected their practice. This demonstrated lessons learned were communicated across the service and translated into action.

The provider reflected on performance and made changes where concerns had been identified. Evidence showed leaders reviewed risks, responded to feedback and implemented improvement initiatives intended to strengthen safety, quality and outcomes for people.