Oaklands 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 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 governance at the service.
 

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. However, the provider’s vision and values were not always consistently reflected in people’s experience of care.

The provider had set out a clear vision for the service. Their Statement of Purpose explained, “We aim to provide the highest standards of care for our residents, where their preferred lifestyles and dignity are respected, and they are supported to live a full and as active life as possible”. We observed examples where these values were not demonstrated within staff interactions and care delivery. We saw times where care was not personalised and people’s privacy were not upheld. This indicated the provider did not always have full and effective oversight of people’s care experience. However, we did also observe positive staff interactions, where staff responded to people’s individual needs with a caring and supportive approach.

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.

There was an established leadership structure within the home. A long-standing registered manager was in post who knew the service and people living there well. They were supported by a deputy manager and clinical lead, with additional oversight from an area manager.

Leaders were responsive throughout our assessment. When we identified shortfalls, the management team were receptive to our feedback and took action to address the issues raised.

People and their relatives were positive about the management of the home. One relative told us, “The manager is supportive to us all.” Another described their overall experience as “unbelievably fantastic”. This demonstrated that relatives generally had confidence in the leadership of the service.

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

People, relatives and staff described feeling comfortable raising concerns and were confident they would be listened to by the management team. The provider had mechanisms in place for people to share feedback, such as, regular relative and staff meetings.

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.

The provider promoted equality, diversity and inclusion within the workforce. Policies and procedures were in place to support fair and inclusive employment practices. The provider had processes in place to address any concerns relating to discrimination, bullying or harassment.

Staff were provided with opportunities to speak up through team meetings, regular supervision sessions.

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

Governance and oversight arrangements were not always effective in identifying, addressing and sustaining improvements in the quality and safety of people’s care. The provider’s own monitoring in July 2026 identified gaps in repositioning records, including gaps of up to 10 hours. Despite this, our assessment found similar shortfalls remained. This demonstrated that actions taken following internal monitoring had not resulted in effective or sustained improvement.

The provider had also previously identified that care plans did not consistently state how often people required repositioning. Although some action had been recorded as completed, this had not been consistently implemented across the home, and our assessment continued to identify inconsistencies in people’s care plans.

Furthermore, people’s pressure care needs and measures to reduce risks were not always accurately recorded, despite the provider’s own pressure ulcer prevention policy requiring appropriate care plans to be in place.

The provider’s oversight arrangements had not resulted in the necessary improvements, with previously identified shortfalls remaining at the time of our assessment, placing people at continued risk of receiving inconsistent or unsafe 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 provider promoted effective partnership working to ensure people had timely access to specialist advice and healthcare services. The service had a weekly ward round where people’s health and well-being were monitored and where required referrals were made to the district nursing team, dieticians and other NHS services.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

The provider had systems in place to monitor the quality and safety of the service; however, these were not always sufficiently robust or effective in identifying shortfalls and driving improvement. Some concerns found during the assessment had not been identified through existing quality assurance processes. This reduced the provider’s ability to demonstrate effective oversight and ensure concerns were recognised and addressed at the earliest opportunity.

Greater management and provider oversight was required to ensure audits and monitoring processes were effective, actions arising from these were clearly identified and progressed, and improvements were embedded and sustained. Quality assurance systems needed to provide greater assurance that people consistently received safe, effective and good-quality care.

Despite these shortfalls, the provider and management team were receptive to feedback and acted promptly when concerns were brought to their attention during the assessment. They demonstrated a willingness to learn and improve and took timely action in response to the issues identified.