Oaktree Homecare Services Limited

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 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.

The provider was in breach of the legal regulation in relation to the governance of the service. Their quality monitoring of the service was not effective which therefore prevented the required improvements. The provider was also previously in breach of this legal regulation. Improvements were not found at this assessment. ​

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. They did not always understand the challenges and the needs of people and their communities.

There was a positive culture in respect of staff treating people with kindness and people being satisfied with the care they received from their regular staff. However, there were times when people’s dignity was not promoted by staff and the provider. Due to shortfalls in quality monitoring there were issues with staff travel time which staff and people sometimes resolved amongst themselves rather than approach the registered manager or office staff to talk this through with them. Some relatives and people were anxious of raising issues and complaints.

The provider and registered manager did not have a good understanding of all their regulatory responsibilities. Essentially what the CQC expects from the provider. The provider did not have a culture of being curious, asking questions and taking advantage of opportunities to learn lessons to make improvements to the service they provided.

The registered management and provider did not have a clear understanding of who the most vulnerable people were at the service, and whether these people were safe. They were not reviewing incidents and accidents effectively to check people’s rights were being promoted and consider if they needed to act to promote their rights.

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders did not always have the skills, knowledge, experience to lead effectively and in an open way.

Staff spoke well of the registered manager, they said they were asked if they had any work issues they wanted to talk about. But people and relatives did not always feel empowered to raise issues about staff practice. When they did the registered manager, and provider did not investigate these issues. When an investigation had taken place, the provider was unable to evidence this.

People did not always feel they could speak up and that their voice would be heard.

People and their relatives did not always feel able to speak up. One person’s relative talked to us about concerns they had not shared with the registered manager. These were serious concerns about potential abuse. A culture had developed when relatives and people were reluctant to speak up. The provider had not identified this as part of their audits and involvement with people and relatives.

Staff told us they could raise work issues with the registered manager, in relation to people’s needs and some said they did speak with the office about how the care visits were organised. However, some people believed some staff did not feel confident to do this.

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 registered manager and provider recruited staff from a variety of different cultural backgrounds. Staff felt comfortable working for the organisation.

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

The provider and registered manager did have some systems to monitor the quality of care. Staff received spot checks, medicines records were reviewed, accident and incident reports were checked. However, there were issues with these audits, for example, when there were missed signatures in medicine records this was not questioned and checked, and medicine care plans were not reviewed as part of this audit. When an accident happened, indicators of potential concerns for the person and staff practice were not identified and investigated. All the audits completed showed positive results, but this did not prompt the provider to question the robustness of these audits, as none had demonstrated any potential improvements or highlighted any lessons which could be learnt.

The knowledge and skill base for quality checking the quality of risk assessments and care plans were not present. We found a number of risks which required further exploration, to ensure the provider understood the risk better. Care plans lacked practical detail to direct staff about all which they needed to do. Those people most at risk were not always known to the provider and registered manager.

New electronic systems had been introduced to make improvements following the last CQC inspection in 2022, but these were trusted to work effectively by the provider. No audits and checks into the data took place to assure and give evidence to the provider, these systems were always working.

Despite a previous rating of requires improvement with breaches of the legal requirements by the CQC and a quality assurance assessment by the local authority, the provider did not have a working action plan to assist them to make the required improvements and provide evidence that improvements were in the process of being made and had been made.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate with them to enable them to make improvements.

There were opportunities to work with other professional organisations which were not identified by the registered manager and the provider when reviewing people’s care, their risk assessments, and incident reports completed by staff. The provider had not actively sought the input from other organisations to assess and help them make improvements with the service provided.

However, the provider did contact the local authority when people wished to cancel their care or reduce their care package.

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.

The provider and registered manager did not have a culture of continuous learning. Opportunities were not taken, and systems did not exist to learn from concerns raised, accidents and incidents, and when a third party raised a safeguarding referral with the local authority. For example, when two safeguarding investigations took place, no work had been completed to look for aspects of practice, records, systems which they could improve upon, the provider had no evidence to demonstrate they had been assured no lessons could in fact be learnt from these safeguarding investigations.