Oak Cottage

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 inadequate. At this assessment the rating has remained inadequate.

This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service continued to be in breach of legal regulation in relation to good governance at the service. We have issued notices to the provider to tell them how they must improve and by when.

This service scored 29 (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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

No staff member was able to describe to us the values or culture of the organisation. The provider had not demonstrated from the highest levels of leadership their values which meant staff did not receive proper guidance on how these core values related to their roles.

The service had moved away from a traditional older persons care service supporting people who also may live with dementia. They at the time of inspection supported younger people with varying support needs, not aligned with their previous model of care. The provider had not developed a strategy to meet both the needs of the new people living in the home and the people who were already living in Oak Cottage. This meant there was no clear framework to ensure decisions and care delivery were aligned with core principles such as transparency, equity, equality and inclusion.

However, staff, many of them long standing employees were positive about the management team. Staff spoke about feeling supported in their roles and that managers were readily available to go to if they needed advice. One staff member commented, “Managers, they are good, accommodating, Managers check how the shift is going, if there are corrections needed. We report things daily to the assistant manager.”

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not embody the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively.

The registered manager and management team led their staff with a sense of openness and honesty. Throughout this inspection the management team have demonstrated their open and transparent attitude to making improvements to the service and have acted with integrity when improvements have been identified.

However, the registered manager and wider management team required further professional development to gain the required skills, experience, and capability to lead effectively. For example, the registered manager and wider management team had undertaken little relevant management training. They were unaware of regulatory changes where The Care Quality Commission assessment frameworks changed extensively. This meant the registered manager was unprepared for the new model and the changes from our previous model of regulation.

Again, staff were positive about the management team, saying they were always available to them, that managers were kind and caring towards them and the people living in Oak Cottage. However, there was little structure around the roles of each manager and a lack of accountability to make improvements happen in a timely manner. This meant that although staff felt supported, the management team did not carry out their role effectively which meant oversight and the development of the service from our previous inspection had been limited and progress was slow.

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

People told us they felt able to speak up if they needed to and would be heard by staff or managers. People said they felt comfortable with speaking out and gave examples where they had done so and said their experience was positive.

Systems were in place to support staff to raise concerns both internally and externally. Staff mentioned they could raise more serious concerns anonymously through whistleblowing procedures with access to external agencies if needed. Staff also said they could speak to the registered manager and all staff spoken with described them as approachable and understanding.

Staff surveys were completed however the feedback from surveys did not feed into a wider improvement plan to develop the service further.

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.

All staff were positive about working at Oak Cottage and felt they were treated with respect. Staff said they felt they worked within an inclusive team which valued their differences. Staff said that by embracing other cultures this helped with their own understanding of how to provide care to people. One staff member said, “I meet other people from different cultures who want to learn different things about me, and I do them. I learn things like supper is different from tea for example, it’s a small thing but it makes me to be interested in those cultural things and embrace them.” A second staff member said, “It’s fun, I get to know lots of things about people from different backgrounds, I get to know the stories. Managers encourage us to all work together as a diverse team and to know that we are all one.”

The provider did not 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.

During our last inspection in November 2024, we found concerns about the safety and governance of the service, and the service was than in breach of legal regulations. At this assessment, we continued to find issues with the lack of effective management and oversight at the service. There was not an improvement plan in place used to monitor areas of improvement in the service. This was created at CQC’s request during this assessment. This demonstrated how the management team did not work cohesively from a shared plan prior to this assessment and one was not in place. Where audits were completed, these were done in isolation and did not feed into the overall quality improvement process as an overarching improvement plan was not previously used. Managers were not clear on whose responsibility audits were or the progress being made on areas they had identified. For example, no manager knew how much work was outstanding with updating care plans, or the extent of the overdue reviews. The lack of effectively operated systems and processes meant there was poor oversight of the delivery of care provided.

The quality assurance processes in place continued to not be effective in addressing the issues found, such as a lack of timely reviews of care, a lack of robust recording in care plans, training that did not support staff in their role, the continued improvements for the environment and poor management around consent.

The registered manager understood their responsibilities under the duty of candour, which requires providers to be open and transparent with people who use services and those acting lawfully on their behalf in relation to care and treatment when things go wrong. However, systems were not operated effectively to report significant events. We have identified incidents not reported to the local safeguarding team, which also were not notified to the Care Quality Commission as required by law.

The provider and registered manager were the same person. There was no external scrutiny of the care provided to ensure the service was well managed. The quality of oversight by the registered manager therefore was not checked, and with their current lack of training, meant there were risks that poor care may go unchecked or unreported. We found this contributed to some elements of a closed culture developing. Ineffective leadership, training and poor application and understanding of Mental Capacity Act [MCA] are all indicators of a closed culture. This is further evident where the provider changed the type of service offered in response to dwindling referrals.

The provider’s oversight and governance of the service had been ineffective in identifying and addressing failings in safety, quality, and standards, as detailed in the Safe, Effective, and Well-Led sections of this report. This contributed to both continued breaches of regulations alongside newly imposed breaches of legal regulation. The provider and / or registered manager did not have clear responsibilities, roles, systems of accountability or good governance. The service lacked a clear vision of the direction and standards they wished to see at the home and had not implemented effective and robust quality assurance systems that led to the delivery of demonstrable improvements

The provider understood their duty to collaborate and work in partnership, but did not apply this in practise as they did not always share learning with partners or collaborate for innovation or improvement.

As previously reported, the lack of oversight and monitoring impacted the effectiveness of collaborative working and sharing of information. This was because learning to develop quality improvement was not routinely taking place. People’s care plans were not always completed, up to date, detailed or accurate therefore we could not be assured that partnership working was always fully supporting effective care.

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.

Oak Cottage has been rated requires improvement in the Well Led domain at 5 out of 6 previous inspections. This demonstrates the quality improvement systems have been ineffective for a significant period in identifying, improving and sustaining the required improvements to meet their legal obligations to provide an effective service.

The provider had not demonstrated the ability to learn lessons or maintain improvements despite investment in care planning systems and external support. A local support agency had spent time developing audits and governance systems with the provider following our last inspection. At this inspection we found much of this support had not been consistently applied to the monitoring and improvement of the service. Subsequently we have found continued improvements that had not been addressed through a framework of learning, reflection, quality monitoring and sustained improvement.

There was no effective process for improving the quality of care for people. Staff did not benefit from frequent lessons learned discussion. This would support staff to reflect on practice and to develop and embed their approach to providing person centred care.

The overall culture of the service was not centred around a consistent focus on continuous learning, innovation, or improvement. The registered manager acknowledged this approach was not yet embedded and although they could provide some examples where this had occurred this was not embedded in practice. For example, improvements were not always identified, and when they were, as we have found at this inspection from our previous finding’s actions were not taken. Shortfalls were not rectified in a timely manner, and systems to measure outcomes and evaluate impact were limited, and improvements were not reliably sustained or achieved.