The 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 inspection we rated this key question requires improvement. At this assessment the rating has changed to 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 was in breach of the legal regulation in relation to governance.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Improvements were required to ensure people achieved positive outcomes and staff were enabled to contribute to the development of the service.

Management staff were aware of the issues and were supporting staff through the changes they were making.

Our findings at this assessment did not evidence that leaders had the capability to ensure the quality and safety of the service was high, quality care was delivered, and risks were well managed.

There had been no registered manager in post since July 2024. A registered manager plays a key role in health and social care services. Their leadership helps make sure people get the quality care that meets their needs. They share the legal responsibility with the provider to meet the legal requirements of the regulations.

An interim manager was in place. Staff, people and relatives spoke positively about them. A relative told us, “Yes, I have met the manager, and she is very approachable. I see her walking around and she will talk to you.”

A new manager had been recruited and was due to start following our assessment. We have written to the provider using our regulatory powers to request that a complete and accurate registered manager application be submitted to the CQC within 3 months of the current manager’s start date.

A new senior management team were in place and monitoring and supporting the home to make improvements.

Improvements were being made to ensure staff felt enabled to speak up. Staff told us that communication and involvement was not always effective. One staff member told us, “They just don’t listen.” Prior to our assessment, staff meetings, supervision sessions, appraisals and training had not been carried out as planned.

An effective system was not fully in place at the time of our assessment to ensure there was workforce equality, diversity and inclusion. Some staff said that teamwork and communication was not always effective. Staff supervision, appraisals and meetings had not been carried out as planned to ensure staff were included and involved in the running of the home.

A system to ensure regulatory requirements were met was still not in place. This is the third consecutive inspection the provider has been in breach of the regulations.

There were shortfalls across the service in relation to the environment, infection control, medicines management, staff support and training, meeting people’s social needs, nutrition and hydration, the assessment of risk and record keeping. The provider’s governance system had not ensured shortfalls were either identified or addressed in a timely manner to ensure compliance with the regulations and make sure people achieved good outcomes.

The provider had formulated an action plan prior to our assessment and updated it during and following our site visits and those visits carried out by the local authority and ICB, to ensure improvements were made.

An effective system was not in place to ensure there was effective partnership working.

The service was in organisational safeguarding at the time of the assessment. This meant the local authority was monitoring the service and supporting them to ensure the correct procedures were in place to keep people safe. The local authority told us this was the third time the home had been in organisational safeguarding procedures within the last 2 years, and previous improvements had not been sustained. In addition, external partners told us that referrals to health care professionals had not always been made in a timely manner to ensure people’s safety and wellbeing.

An effective system was not in place to identify and share lessons learned. This is the fourth inspection that the provider has failed to achieve a rating of good since 2018. We have taken this into account when scoring this quality statement. We identified shortfalls in relation to the assessment of risk, medicines management and the environment which had been identified at previous inspections. Staff supervision, appraisals and meetings had not been carried out as planned to share lessons learned and identify actions to help reduce the risk of reoccurrence.