Oakley Lodge

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 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.

People and relatives described a positive and caring culture. People were encouraged to be independent, take part in their communities and pursue goals that were important to them.

Staff described a culture focused on supporting people to achieve positive outcomes and improve their quality of life. Staff and leaders shared a commitment to helping people access opportunities, maintain their independence and live fulfilling lives.

Leaders promoted a clear vision based on inclusion, opportunities and person-centred support. Overall, staff described leaders as approachable, open and supportive.

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.

People and relatives spoke positively about the registered manager and described them as approachable, supportive and committed. People knew the registered manager by name and told us they felt supported by them.

Overall, staff described leaders as approachable, open and responsive. Leaders demonstrated a good understanding of the service, its values, regulatory responsibilities and the needs of people using it. Records demonstrated leaders met their regulatory responsibilities appropriately. The registered manager was visible throughout the service and known to people, staff and relatives. We observed them supporting people and providing guidance and support to staff.

Leaders demonstrated a commitment to their own learning and development and described receiving support, training and constructive feedback to help them lead effectively.

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 were confident they would be listened to. Staff were aware of speaking up and whistleblowing processes, including how to raise concerns anonymously if needed.

Leaders promoted an open and supportive culture and encouraged staff to speak up when they had concerns. Staff described leaders as receptive to feedback and told us they felt listened to when issues were raised.

Policies and procedures were in place to support speaking up, and information about how to raise concerns was displayed within the service. Leaders demonstrated a clear understanding of their responsibilities in relation to whistleblowing and protecting staff who raised concerns.

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.

Overall, staff described a supportive and inclusive working environment. They told us leaders promoted a culture where staff were treated fairly and individual circumstances were considered.

Leaders demonstrated an understanding of equality, diversity and inclusion and described work undertaken to improve workforce culture and ensure all staff felt valued and respected. This included promoting appreciation of different cultures and recognising the contributions of all staff.

Leaders described processes for identifying and addressing concerns relating to discrimination, bullying and workplace culture. Staff were encouraged to raise concerns and leaders sought feedback and support where needed to help create a fair and inclusive working environment.

The provider did not always have effective systems of governance and oversight. Quality assurance processes had not always identified concerns relating to medicines management and record keeping.

We identified shortfalls in governance systems relating to medicines management and record keeping. Some medicines recording and documentation issues had not been fully identified through the provider's existing quality assurance processes. We also identified opportunities to strengthen the recording and evidencing of progress towards people's goals and outcomes.

Whilst there was no evidence people had come to harm, these issues increased the risk of inconsistent recording and oversight. Leaders responded promptly to the issues identified during the assessment and took action to strengthen governance processes, oversight arrangements and documentation. However, further time was needed to ensure these improvements were fully embedded and sustained.

Despite these issues, governance systems were in place to monitor quality, safety and performance. Overall, people, relatives and staff were positive about management oversight and the improvements made under the current leadership. Leaders used audits, action plans, surveys and quality monitoring processes to review performance and drive improvement. Leaders were open and transparent throughout the assessment, and records demonstrated appropriate management of regulatory responsibilities, including the submission of notifications and safeguarding referrals where required.

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.

Staff and leaders worked with relatives, healthcare professionals and other agencies to help ensure people received coordinated care and support. People benefited from strong links with healthcare services, community organisations and those important to them.

Professionals generally described the provider as open, responsive and willing to engage with advice and feedback. Records and discussions demonstrated ongoing partnership working to support positive outcomes for people.

The provider had identified opportunities to further strengthen communication and information sharing across some partnership arrangements and was using this learning to improve communication, oversight and joint working. Overall, feedback demonstrated effective collaboration with relatives, healthcare professionals and partner organisations to support people's care and wellbeing.

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.

Staff and leaders used learning from incidents, feedback, audits and reviews to improve people's experiences and outcomes. Overall, professionals described the provider as open and reflective, with a willingness to review practice, share information and work collaboratively to improve support.

The provider used a range of tools and approaches to support improvement and innovation, including electronic care records, communication aids and technology to support the identification and monitoring of health needs. For example, a pain assessment tool helped identify changes in a person's health and facilitated timely healthcare intervention.

Leaders demonstrated a commitment to continuous improvement and were working towards National Autistic Society accreditation to further review and improve support for autistic people.

Whilst leaders responded promptly to the governance and medicines issues identified during the assessment, these had not all been identified through existing quality assurance processes. Further time was needed to ensure the improvements made were fully embedded and sustained.