Oakworth Manor 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 requires improvement. At this assessment the rating has remained 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.

This service scored 54 (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. Staff understand the challenges and the needs of people and their communities.

Leaders needed to make improvements to ensure consistency towards communication. People received a good experience of care from staff. However, more work was needed by leaders to ensure there was a drive for continual improvement and they recognised and responded to areas which were below expected standards. Leaders needed to create a culture to positively challenge poor practices in a safe way to ensure there was an approach to development and improvements.

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

Leaders needed additional time to focus on the quality and visibility of leadership at the service. The registered manager was responsible for another location a significant distance away. They spent one day a week at Oakworth Manor Care Home. This negatively impacted the service where there were inefficient systems to have a strong managerial oversight of quality and performance at the service. The lack of detailed oversight was evidenced in the quality of record keeping and quality checks. The registered manager’s registration of two care homes was a temporary arrangement. However, in light of the improvements needed at the service, it was felt following the inspection, this arrangement was not working to assure good governance oversight at the service. The absence of a registered manager at the service most of the time impacted staff’s awareness of the availability of the registered manager when they were not on site.

Staff had access to team meetings, supervisions and handovers. Staff told us they felt able to speak up and they would be listened to.

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. Staff told us leaders were inclusive and fair towards staff.

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.

Provider audits were not robust in identifying areas of improvement. While leaders completed audits, these did not identify the issues we found on inspection. The quality of audits and checks were not robust to clearly demonstrate analysis had been completed. This affected the provider’s ability to monitor patterns and trends which may have required action to keep people safe from future incidents. Leaders admitted that their audits did not review all aspects of people’s documentation, such as risk assessments, where we found improvements were needed. While we found the care people received was of a good standard, people’s care plans and risk assessments were of poor quality and audits were not effective in identifying this. Leaders also did not complete observations of care at key times, such as at mealtimes or medication administration, to recognise and identify where improvements were needed. The registered manager did not submit all incidents to CQC which they are legally required to do. This was actioned during the inspection and assurances were given this would not happen in the future.

The provider was in breach of the legal regulation relating to the monitoring of quality of the documentation and having adequate oversight of risks and improvements needed.

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 felt confident to work in partnership with visiting health and social care professionals. We found staff correctly escalated any changes in a person’s care need, to make sure they got the right medical attention.

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.

Improvements were needed to ensure consistency of quality across records, the management of medication and clear communication at mealtimes. We found care records were confusing, contradictory and people were not consulted and included in their care plans in a meaningful way. Improvements were needed to create a positive learning culture with clearer communication where lessons needed to be learnt and where improvements were needed in record keeping.