Oakham Grange

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 changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The provider was previously in breach of legal regulation in relation governance at the service.Enough improvements had been made at the service and the provider was no longer in breach of the regulation.

This service scored 68 (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.

There was a positive culture in the service which focused on effective care and support for people. Staff spoke highly of the registered manager and how their supportive leadership and their commitment to people they supported and staff. Staff were positive about how the team engaged in helping improve people’s quality of life. A staff member said,“I get along well with everyone I work with, and we have a good working relationship as a team. I also feel there’s a positive and supportive relationship with the management.” Another staff member told us, “I like looking after people and the compassion shown when they need help and support. I enjoy making people happy.”

Managers ensured staff received training, support and access to policies, procedures and systems, to help them provide person-centred care. They used audits and checks, supervision and staff team meetings to make sure staff understood how the provider’s values should be achieved through their working practices.

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.

The registered manger and deputy manager were passionate and committed to ensuring people at the service received high quality, safe care.Staff described managers as responsive, approachable and committed to ensuring care was delivered safely and effectively. Staff expressed confidence in the leadership team and reported high levels of trust in the registered manager and deputy manager. During the inspection, we observed the registered manager engaging directly with people and staff.

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

There were processes in place to allow people, relatives and staff to raise concerns and / or share ideas. A staff member told us, “We can speak up in staff meetings; they are twice a month. I have attended a few, if I miss any there are minutes.” Another staff member said, “There is an open culture here, mistakes can happen but as soon as you realise it, you do something about it.”

Staff felt confident to raise concerns with people outside of the organisation such as GPs, local authorities and CQC to safeguard people they cared for.

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 provider had developed an inclusive and diverse workforce, recognising the strengths and perspectives that different backgrounds bring to the team. Staff reported they felt respected, supported and valued in their roles. They described a workplace where equality and diversity were promoted in day‑to‑day practice and where opportunities for development were accessible to everyone. A staff member told us, “Oakham Grange promotes equality and diversity as is evident in our staffing. I feel respected regardless of my background, and there is an inclusive environment where cultural differences are acknowledged and respected.”

The provider also offered practical support for individual needs, including access to a prayer room within the service, which staff could use when required. One staff member told us, “The management team and organisation are very considerate of this [ethnicity and cultural needs], everyone's needs are well thought through. Staff who need to offer prayers have been provided with a separate room for privacy.”

The provider had clear responsibilities, roles, systems of accountability and good governance.

There were governance systems in place to monitor the quality and safety of the service. Regular checks were completed across key operational areas, including the environment, equipment, incidents, accidents and medicines. The registered manager and deputy manager undertook a programme of audits designed to assess the quality of care and review people’s experiences. Findings from these audits were used to develop action plans that set out where improvements were required and how these would be achieved.

However, while auditing arrangements were established, the provider needed to strengthen their medicines auditing processes and care monitoring records. The audits completed had not identified the issues we found during the inspection, which meant they were not always sufficiently robust to ensure safe oversight of medicines management.

The provider’s senior manager also carried out routine governance visits to the home. This additional level of oversight supported accountability and contributed to ongoing quality improvement across the service.

The provider understood their responsibility to collaborate and work in partnership so that services were coordinated and responsive to people’s needs. The service worked effectively with a range of external professionals, including GPs, community nurses, mental health services and specialist teams. Most visiting professionals were positive about the staff team and how they worked with them.

Staff encouraged and supported people to be a part of the local community at the service by spending time with each other in communal areas and taking part in shared interests and pastimes. One person told us, “I’m not a big joiner but I may just listen. I like to read or go for a walk. My [relative] takes me to church and [activities staff member] has organised trips in small groups to take us to the local pub for coffee or a drink.” A relative commented, “We enjoy the garden here. It’s a good range of activities and [relative] likes the music or when children come in and play bowls or games with people.”

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.

Leaders demonstrated a commitment to learning and continuous improvement, and significant improvements had been made since the last inspection. Systems and processes had been strengthened, and staff were responsive to feedback and support. However, auditing processes were not yet fully effective in identifying and addressing all areas of concern. During the inspection, issues were identified relating to medicines management and pressure area care records that had not been recognised through the provider’s own quality assurance systems. This indicated further work was needed to ensure processes were sufficiently robust, consistent, and effective in driving sustained improvement and oversight.

Incidents and accidents were subject to thorough analysis, with clear learning identified and routinely shared with staff. Learning outcomes were discussed in team meetings and prominently displayed in staff areas, prompting ongoing reflection, questions and constructive conversations.